Auditing falls .. where to begin?

  1. I've been given multiple cases to audit. All of which relates to falls within the hospital. Did a big research on falls and prevention, yet I feel whatever I have to say will be nothing the managers/committee hasn't heard before.

    Is there anyone out there that has the magic answer to preventing falls? Fall risk assessment tools, a check system, etc they love and wouldn't mind sharing? All is appreciated.
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  2. 7 Comments

  3. by   HouTx
    Magic pixie dust???

    Hey, I feel your pain. All of a sudden, this is a huge issue for the C-Suite. They're demanding results RIGHT NOW. ..... as long as the fix doesn't require more staff or equipment, amiright?

    We're analyzing falls with greater granularity than before. If you're extracting data, you may want to adopt a framework that will permit you to objectively classify each incident by categories such as: severity, time of day, staffing variables, patient characteristics, etc. For benchmarking purposes, be sure to use the same rate as the comparisons - usually falls per 1000 patient days or something like that. However, if you're communicating to staff - use the raw incident numbers. There is abundant literature on falls that I'm sure you have probably already digested.

    We're also incorporating some other changes that we hope will help. Standardized hourly rounding is being enforced... we had it, but it wasn't really hardwired. We've upgraded our "sitters" - changed the name to private patient attendants (sitter gave the impression that all they did was sit .. and many took that to heart) & providing them with education and competency validation. We're using more technology such as bed alarms & CC cameras for high risk patients. We're designing visual reminders for the rooms. Staff have contributed more ideas such as eliminating KVO IVs - reduce trip hazard equipment around the bed and make it easier for ambulatory patients.

    We'll see ... fingers are crossed, but I do have the pixie dust on order.
  4. by   Oh'Ello
    I'll tell ya this right freakin now. Yellow wristbands DO NOT HELP.
  5. by   Double-Helix
    After each fall, gather the immediate staff together (RN/LPN, CNA) and ask “why did this fall happen?”, “Can it happen to any other patients?” and “What can we do to prevent it from happening?” If you find that the circumstances contributing to the fall are likely to happen again (such as a cluttered room, poor staffing leading to long wait times to answer patient call bells, etc.) translate the answers into an action plan.

    Do some research into best-practice fall interventions as well as CSM/JC requirements for fall risk assessment and prevention interventions. Do you have any existing evidenced-based fall prevention policies? If so, audit your compliance with the intervention and see if you can identify areas that require improvement.
  6. by   Here.I.Stand
    Quote from Oh'Ello
    I'll tell ya this right freakin now. Yellow wristbands DO NOT HELP.
    Especially when every pt wears one.
  7. by   amoLucia
    Quote from Oh'Ello
    I'll tell ya this right freakin now. Yellow wristbands DO NOT HELP.
    Nor do the yellow stars, 'falling stars' or 'falling leaves' plastered on doorway frames!!!
  8. by   Eric Cartman
    Fall prevention is a hot topic right now at many acute healthcare facilities. As has already been mentioned in others posts, the biggest questions are why did the fall occur and were all interventions in place to prevent the fall? In my experience most falls seem to have a contributing, controllable factor which is really annoying. For example slip resistant socks were not on, bedside table was too far away, telephone was too far away, call bell fell onto floor, patient was scored incorrectly on the fall risk assessment scale, patient on BP or pain meds, new onset of confusion, family turned the bed alarm off because it was annoying and so on... All falls seem to have a cause, but is the cause always preventable? That I can't answer and don't know if anybody else can. I guess that is the purpose of root cause analysis when we do have falls, especially falls with injuries.

    Just out of curiosity, what fall scoring system or scale does your hospital use HouTx? Last year our hospital just adopted the Johns Hopkins scoring system. I can't tell if it has really made a difference or not.
  9. by   gcupid
    Quote from Eric Cartman
    Fall prevention is a hot topic right now at many acute healthcare facilities. As has already been mentioned in others posts, the biggest questions are why did the fall occur and were all interventions in place to prevent the fall? In my experience most falls seem to have a contributing, controllable factor which is really annoying. For example slip resistant socks were not on, bedside table was too far away, telephone was too far away, call bell fell onto floor, patient was scored incorrectly on the fall risk assessment scale, patient on BP or pain meds, new onset of confusion, family turned the bed alarm off because it was annoying and so on... All falls seem to have a cause, but is the cause always preventable? That I can't answer and don't know if anybody else can. I guess that is the purpose of root cause analysis when we do have falls, especially falls with injuries.

    Just out of curiosity, what fall scoring system or scale does your hospital use HouTx? Last year our hospital just adopted the Johns Hopkins scoring system. I can't tell if it has really made a difference or not.
    Is the cause always preventable? No.
    In my experience, most falls have a contributing, controlling factor which is really annoying to me as well.
    Sesame street, The word for today is "Staffing."

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