HQSC Quality & Safety Challenge 2012

Real Time Data Gathering of Factors Associated with Falls in a

Hospital Setting

Ken StewartJan Nicholson

Key Components

Collecting information as soon as possible after a fall Interviewing the patient, family/caregivers and staff Comparing independent data collection and

qualitative information with clinical records Reviewing 233 falls over 4 months in 8 wards

(154 fallers)

Study Questions

Are the 5 key elements of a falls prevention strategy documented in the clinical record and implemented?

Is there variation between what’s documented and what actions are actually occurring?

Is there an opportunity to generate patient stories that reflect the key elements of fall prevention management?

Is there an opportunity for the study nurses to reflect upon key elements of falls prevention and identify improvement activities?

Key Elements – “the basics”

Screening for falls at every admission

Identifying patients at risk of falling and documenting findings in the clinical record

Putting appropriate falls prevention strategies in place

Renewal of risk assessment and implementing new strategies post fall

Documenting a long term falls prevention strategy

The Findings

91% of fallers had been screened for falls risk on admission to ward

88% of the time a falls risk assessment had been completed prior to the first fall

Implementation strategies were often in place but not consistently recorded in the clinical record

Falls risk assessments are renewed after a fall 56% of the time

Long-term falls prevention strategies are not consistently recorded or implemented

The Findings continued…

Consistently low rates of “strategies in place” for:

communication with the patient’s family

toileting strategies

delirium management

medication chart reviews

new strategies in place post fall

implementing a long term falls prevention strategy.

The Findings continued…

There is value in using stories to “walk in our patient’s & family’s shoes”

The study demonstrated the value of “nurse fall champions” in hospital setting

A number of opportunities for improvement have been identified

Where to now

Address key issues identified where the basics are not delivered or consistently implemented

Replicate the study strategy in other hospital areas Inform the facilities planning process to reduce

harm from falls