Staff Engagement in Patient Safety and Fall Prevention Leading to Decreased Adverse Events

Purpose:
Decreasing patient falls and falls with injury led to the creation of an enhanced fall prevention program.The innovative program included evidenced based tactics.The efforts included interdisciplinary collaboration.Patient safety and safe patient handling practices were part of the initiative.

Relevance/Significance:
Falls affects the patient, staff and families.The greatest impact is realized for the patient.An evaluation of the practices and outcomes provided resulted in an increased knowledge about the impact of a fall, the critical need to increase interventions and provided invaluable education about falls.The staff learned to rely on critical thinking skills, not only the fall risk score.The significance of a patient reported fall within the last year placed the patient at high risk for a fall.

Strategy and Implementation:
An initial audit revealed the greatest at risk population for our hospital was the 55 – 65 year old female. A presentation to leadership and staff included the falls data and audit results and the team identified barriers and needs.A patient safety agreement, additional signage, scripted patient education and concentrated effort to decrease falls through vigilant evaluation and education started the process momentum. A cultural shift to was realized. Ongoing education and improvements included the addition of a Patient Fall Risk Self Assessment, ABCS Risk for Injury, increased education to support hourly rounding, bedside reporting and targeted toileting combined with written, verbal and reinforced patient education.The increased use of gait belts and other assistive devices improved outcomes.The program included the outpatient and ancillary departments.Daily organizational and unit safety huddles focused on patient with falls and the discussion related to recent falls occurrences.

Evaluation:
Over 2 ½ year period the organization reduced falls by 40 percent. Education, multiple interventions and unit specific gap analysis and action plans aided in the reduction of falls.The staff was educated on safe patient handling practices to decrease employee injures. The staggered approach and integration current and new practices facilitated the adoption into practice.

Implications for Practice:
The ability to improve and engage the patients and families led to success.Decreased falls equals improved patient outcomes, decreased employee injuries and improved financial outcomes.A cultural shift to a cohesive team focused on improving the environment and patient outcomes was realized.