FALL PREVENTION

QUALITY IMPROVEMENT PROJECT

Philippe Martin
Ray Velasco
Sayuri Yoshimura
Supattra Allen

Summary of the Problem

Who are the key players?

66 year old female

Pneumonia, mild respiratory distress

Weaned off O2

Patient

Nurse assisted patient onto shower chair

Call light within reach
Housekeeper cleans room, spills water
pitcher
Housekeeper mops up water and leaves

Primary nurse

Patient goes back to bed post shower in

socks
Lightheaded, slips on wet floor

Patient crying on floor, fractured left hip

Housekeeper

Patient Falls in the Hospital Settings

More than
1 Million Falls
Occur every
year

Hawaii
In 2010, Hawaii spent over $112 million in hospital medical
charges for fall-related injuries

1,990 hospitalizations and over 5,700 emergency department

visits each year as a result of falls among older adults
30% of Falls result in injury
10% of Falls result in serious
injury
Such as Head Trauma, Fracture
American Nurse Association.(2013).

85 deaths from falls per year among elderly

Department of Health. (2013)

QI Tools for Root Cause Analysis

Root Cause Analysis...
Identifies what happened
Identifies why it happened
Identifies what to do to reduce the likelihood of the problem happening again.

Ishikawa diagram (cause and effect/fishbone)

Allows its users to consider all possible causes of a problem, rather than just the most obvious ones.
When to use fishbone diagram:

To identify many possible causes for an issue or problem.

Identify where and why process isnt working

How to use the tool:

1. Identify the problem

2. Work out the major factors involved

3. Identify possible causes
4. Analyze your diagram

The Cause and Effect Diagram

Nurse did not remain
with the patient during
showering

Personnel

Housekeeper did not put

caution sign on the floor
No communication
between the nurse
and housekeeper
The nurse did not
communicate to
the patient to call for
assistance before
ambulation

Communication

Patients
Cognition/Judgment
Patient did not
use call light
when finished
showering

Fall
Wet floor without
caution
sign

Environment

QI TOOLS PDSA
PLAN-DO-STUDY-ACT
A four step model used for improving a process or carrying out change. The PDSA cycle should be used repeatedly for
continuous improvement.
When to use PDSA?

As a model for continuous improvement

When starting a new quality improvement project

When developing a new or improved design of a process, product or service

When implementing any change

How to use PDSA

1. PLAN: Recognize an opportunity and plan a change
2. DO: Test the change. Carry out a small scale study

3. STUDY: Review the test, analyze the results and identify what you have learned
4. ACT: Take action based on what you learned in the previous step. If the change did not work, go through the cycle
again with a different plan. If you were successful, incorporate what you learned to plan new improvements.

QI process using the PDSA

PLAN
Questions:
How can we ensure prevention of unanticipated falls?
How can we ensure compliance of fall risk injury assessments for all patients?
Prediction:
The implementation of a multifactorial fall prevention management program will significantly
reduce and prevent fall rates.
Implementing visual cues in admission packets will help ensure compliance with fall risks
assessments
Assessment:
Compare fall rates of pre and post intervention

Top Down Flow Chart Tool of the Process for Preventing Falls
1.0
Patient Admitted to Ward
2.0
Assessed for Fall Risk Factors Daily

Diagnosis

Mobility/Transfer Abilities

Toileting Needs

Mental Status

Medication

Environmental Risks

Hx of Falls

Vision
3.0
Risk Factors Identified
Implement Universal Risk Precautions Plus Tailored Plan
based on Identified Risk Factors
4.0
Implement Fall Precautions

5.0
Individualized Care Plan
Check for Injuries and Administer Treatment
Determine if Doctor or Ambulance is Needed (as per
facility protocol)
Notify Doctor of Fall, Regardless of Injury
Complete an Incident Report
Reassess Resident (fall risk assessment)
Review Existing Strategies and Determine Need for
Any Additional Strategies, Including Injury Minimisation
Strategies (eg hip protectors).
6.0
Discharge
Patient education
Interdisciplinary referrals.
OT & PT

Do
Multifactorial Fall Prevention Management Program
1. Complete a thorough fall risk assessment upon admission.
1. Reassess patients after any significant changes e.g. altered level of consciousness, changes in
mobility, medications
2.
3.
4.
5.

Post visual cues on patient, EMR, and door to alert staff of high risk for falls/injury patients.
Ensure appropriate footwear in use (eg non-skid socks)
Effective communication among staff regarding patient risk for falls (eg fall assessments)
Communicate effectively with high risk for fall patients to use the call light for nursing assistance
before activities or ambulation
6. Educate patient and families in fall prevention and what to do after a fall.

STUDY
Run Chart Tool Showing a Downward Trend After Fall Prevention Bundle Implementation in May in 5 East

Study:
Data Needed to Evaluate Success of Program
What is the hospitals current fall prevention policy toward interventions to prevent patient falls
from occurring?
How well did the staff comply with the fall prevention policy?
What were the risk factors that triggered the patient fall?
What were the interventions used to prevent falls?
Were the interventions effective?
Is there a trend?

Study: Complete analysis of data

According to the article, Journal of Nursing Care Quality, there were no falls among any of the
patients who received patient and family education as part of the fall prevention program in
a neuroscience unit in an acute care hospital.

According to the article, The Joint Commission Journal on Quality and Patient Safety,
hospitals that adopt four Key Strategies and tactical recommendations to prevent falls and
fall Injuries in acute care setting saw a significant decrease in falls. (assessment and reassessment of patient risk factors for falls; visual identification of patients at high risk;
communication of patient fall risk status; education of patients, families, and staff about fall
prevention)

Act
Our findings show 0 falls after implementing the fall prevention bundle in May. The
fall prevention bundle will be standardized to apply to the whole hospital.

Use findings the from the study to standardize and implement any changes. If
successful, implement interventions into a bigger population. After some time,

begin step 1 and re-examine the process to learn where it can be further improved.

Recommendations
Communication between staff
Improving communication within staff is a critical strategy for increasing fall prevention
(Wagner et al., 2010).
Patient education
Patient education, especially face to face, on fall prevention was most effective at reducing
fall rates (Lee et al., 2013).
Patient education to communicate to staff reduces fall rates (Rym et al, 2009). Call, Dont
Fall
Fall prevention management programs
Implementation of fall prevention/management programs reduced falls by 58% (Trepanier
& Hilsenbeck, 2014).

References
American Nurse Association.(2013).Hospital-Based Fall Program Measurement and Improvement in High Reliability Organizations. Retrieved from
http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Fall-ProgramMeasurement.html
Department of Health.(2013).Hawaii Falls Prevention State Plan. Retrieved from http://www.hawaiiadrc.org/Portals/_AgencySite/2013Falls.pdf
Lee D., A., Pritchard E., Mcdermott F., Haines T., (2013). Fall prevention education for older adults during and after hospitalization: a systematic review and
meta analysis. Health Education Jounral. January 2013, Vol. 73. No. 5.
Rym, Y.,Roche, J., Brunton, M. (2009). Patient and family education for fall prevention: involving patients and families in a fall prevention program on a
neuroscience unit.
The Joint Commission Journal on Quality and Patient Safety (2007).
https://www.ascensionhealth.org/assets/docs/JCAHO_Eliminating_Falls_at_Ascension_Health_July_2007.pdf
Trepanier, S., & Hilsenbeck, J. (2014). A hospital system approach at decreasing falls with injuries and cost. Nursing Economics, May-June 2014, Vol. 32, No.
3.
Wagner L. M., Damianakis T., Mafrici N., Robinson K., L. (2010). Fall communication patterns among nursing staff working in long-term settings. Clinical
Nursing Research, 19(3), 311-326.
Windia, U., W., (2013). The effectiveness of fall prevention/management program in reducing patient falls: A restrospective study. Reducing patient falls: A
retrospective Study.