"Drilling Down" on Patient Falls: Implementation of an Intensive Falls Analysis Process

Purpose:
Falls rates on some units in a cancer center remained higher than their NDNQI comparison groups. An innovative process using a fall analysis tool, NDNQI, and incident report data was developed and implemented. Results have been used by units to design interventions to successfully reduce falls.

Significance:
Patient falls, the most frequently reported adverse event in adult inpatients, often result in harm, increased length of stay, and higher costs. Payment from the Centers for Medicare & Medicaid Services for costs associated with injuries associated with hospital acquired falls no longer occurs.

Strategy and Implementation:
A systematic strategy to intensively analyze patient fall data was developed. Units with sustained fall rates exceeding their NDNQI and National Cancer Center (NCI) comparison groups participate in a focused fall analysis process. Data sources include unit specific fall data displayed graphically in relation to NDNQI comparison group means and NCI hospital medians. Elements include: fall and fall injury rates, hours per patient day, percent of unassisted falls, patients risk assessed within 24 hours, patients at high risk, and assessed and on the fall protocol. Detailed incident report information is reviewed and an Injurious Fall Data Collection Tool from the Institute for Healthcare Improvement is completed by the unit. Results are analyzed to identify factors or trends specific to the unit's population and used to develop a “falls bundle”. This bundle serves as the basis for tailored interventions aimed at reducing falls, implemented in conjunction with as existing fall program.

Evaluation:
Results are displayed and evaluated monthly; findings are compared to quarterly NDNQI and NCI data. Information is shared with nurse leaders and unit staff. Units participating in this process to date have reduced fall and injury rates to levels at or below the NDNQI and NCI comparison group means.

Implications for Practice:
This systematic patient fall review and analysis process allows nurse leaders and staff at the local level to actively use data to develop unit and population specific interventions to reduce falls. Benchmarking and active participation promotes investment in the process and outcomes.