Patient Falls Down!

Purpose:
For 600 bed hospital system, work was previously done to address reducing patient falls with injuries. However, a Six Sigma team discovered that the total number of falls had not decreased in over two years of study. This group's strategy was to reduce total patient falls by 60% over three years.

Significance:
Patient falls result in added cost to the health care system, as well as significant patient discomfort and injury levels, and longer lengths of stay. It is estimated that by 2020 the total cost of all fall injuries in patients older than 65 will exceed $32 billion.

Strategy and Implementation:
Using Six Sigma strategies, the team gathered and analyzed 2 year's of data on falls occuring at both campuses using the NDNQI definition of a fall as "any unplanned descent to the floor." Patient characteristics as well as planned nursing interventions prior to and post fall were examined. There were three units which stood out as having the majority of falls; these were: oncology, medical surgical, and inpatient rehab. Working with staff from these units along with members of the nurse quality, practice, and research councils, literature review and best practices were identified. These units then served as pilot units for rapid cycle testing, and gaining staff input. Education was planned for all staff (not just nursing), and the new strategies were deployed which included: a colored coverlet to be present on top of the patient and/or bed at all times, colored socks and armbands, new signage and a family-voice activated bedside alarm to remind patients to wait for help.

Evaluation:
Total falls continued to be monitored, as well as audits for compliance by staff on all interventions. Additionally, a RCA was performed after each fall by the staff involved. Trials began in February 2010, and to date, there has been a 17% reduction of falls.

Implications for Practice:
Improving patient safety was paramount. These new interventions allow for visual cues for all members of the healthcare organization to recognize patients that are at risk for falls. Nurse staff report higher satisfaction in knowing the new strategies are maintaining safer conditions for patients.