Remapping Fall Reduction Program with Accountability for Sucess

Purpose:
Increasing staff awareness,participation and accountability related to fall prevention will decrease patient falls through opportunities of lessons learned and identified common trends. A successful unit based fall champion role empowers staff to have a span of positive influence on peer behaviors.

Significance:
The current fall prevention strategy is evidenced based and components are combined in a bundle emphasizing the importance of the sum of all components. Emphasizing the bundle compliance of all fall risk patients and staff accountability to follow through with interventions.

Strategy and Implementation:
Following trends of falls the Fall Team was able to: Standardize post fall safety huddles improving post fall information facilitating cleaner data to trend. Process streamlined and supported with leadership team emphasizing bundle compliance with staff. Drilldown of fall completed at time of fall with care team and information presented in SBAR format and shared both on a unit level and hospital wide. This standardized approach utilizing simple tools and clear process improved staff satisfaction with ease and transparency. Monthly "Shout outs" celebrate units with no falls. Bathroom safety addressed through a multi-disciplinary team developing a bathroom safety checklist, assessing all patient bathrooms and remodeling where indicated. Family education addressed and signage posted “partnering with the care team to keep your loved one safe” campaign. Hourly rounding incorporated toileting and communication of level of assistance on whiteboards adhered to.

Evaluation:
Effectiveness of process demonstrated with the decrease in Falls per patient days. 2009-2010 rate 3.32, 2010-2011 rate 2.84, 2011 -2012 rate 2.21 and current rate 2012-2013 2.02. Increased staff awareness through timely reporting and trending of falls through out hospital.

Implications for Practice:
Combination of evidenced based bundle and staff accountabilty sets a clear expectation for care of teh fall risk patient. Bundle components are ; mobility alarm or bed alarm utilization, toileting every two hours, communication of level of assistance on whiteboard and providing level of assistance.