Poster Presentation
Sunday, November 4, 2007
10:30 AM - 11:45 AM
Sunday, November 4, 2007
1:30 PM - 2:45 PM
221
Transdisciplinary Approach to Fall Prevention
Jill Marie Larkin, RN, MSN, MBA, Patient Care Services, UPMC Passavant and UPMC Passavant Cranberry, Pittsburgh, PA, USA and Cheryl V. Dodson, RN, MBA, Patient Care Services Administration, UPMC Passavant and UPMC Passavant Cranberry, Pittsburgh, PA, USA.
| Learning Objective #1: identify fall prevention strategies that can improve patient safety. |
| Learning Objective #2: describe how a transdisciplinary team can sustain positive patient safety outcomes. |
Assessment completed through real time root cause analysis of every fall. Common risk factors identified prior to the fall included: polypharmacy, medications causing confusion/delirium, history of falls, mobility limitations, and toileting.
We shifted from a nursing team to a transdisciplinary team consisting of Leadership, Physicians, Nursing, Pharmacy, Physical Therapy, Maintenance, Safety/Risk. Our focus shifted from falls being an isolated event to a complex clinical syndrome with potential for significant morbidity/mortality that needs to be recognized, evaluated, treated, and prevented.
Education included interactive classes, online CME’s, and “Equipment Fair”. A Post Fall Assessment Team responds to falls 24/7 to examine the risk factors’ “real time”, serve as a resource, and implement strategies. Limiting sleeping medications on the formulary, administration time prior to midnight, and activating bed alarms was successful.
To promote a positive culture, a reward program celebrates “number of days” departments are “falls free”. Documentation analysis resulted in the following improvements: admission order sheets revised to decrease automatic ordering of sleep/anxiety medications, assessment forms designed by staff to an efficient 5-event sheet, and a post fall “sticker” enhanced communication.
Beyond data, our success is seen in the culture shift from a nursing isolated event to a transdiciplinary team approach to attack a complex clinical syndrome. We have heightened awareness of staff to provide a patient safe environment.
Patient Fall Reduction Program has resulted in a significant decrease in falls with wide statistical variation in July 2003 of 7.7 to an entire 12 month period below target in 2006 with a low of 1.94 falls per 1000 patient days in April, minimized variation of data, and a trend line that continues downward along with the falls injuries.
We are continuing with real time review of every fall and implementing additional Pharmacy changes. Our goal is to “Keep Our Patients Safe”.