Harnessing the Multidisciplinary Team & Available Technology to Reduce Patient Falls on a Telemetry Unit

Purpose:
To utilize the Learning from Defects tool and Translating Evidence into Practice model to identify and implement an intervention to reduce patient falls on a 20-bed telemetry unit with a goal of reducing falls below the NDNQI 10th percentile.

Significance:
Falls are the most frequently reported adverse event in the adult inpatient setting with up to 1 million occurring each year in the US. Significant injury and death can result from these falls, but all falls are preventable.

Strategy and Implementation:
We developed this project in the unit's Comprehensive Unit-based Safety Program (CUSP). We used the Learning from Defects tool to identify an intervention. We reviewed falls on the unit over 12 months and concluded that bed alarms being turned off were an important contributing factor. Thus, we initiated independent double checks of bed alarm status by a unit clerk or charge nurse every 4 hours for patients at high fall risk. A patient's nurse was notified if the bed alarm was off. We used the TRanslating evidence Into Practice (TRIP) model to implement this multidisciplinary intervention and improve the reliability of care for the patient. In step 4 of this model we engaged, educated, executed, and evaluated to ensure that all patients received the intervention. The intervention was implemented in November, 2009.

Evaluation:
The fall rate decreased from 2.69 to 1.34 falls/1000 patient days pre- and post-implementation and thus fell below the NDNQI benchmark. Using Poisson regression, we obtained an incidence rate ratio of 0.50 (P=0.19) indicating a 50% relative risk reduction in falls.

Implications for Practice:
Use of this low-burden, multidisciplinary intervention should help other hospitals meet and surpass the recommended benchmark for fall rates.