Objective: Falls are the largest category of adverse events in hospitals. In response to the 1999 Institute of Medicine report, “To Err is Human,” our hospital initiated 15 teams to reduce errors, including one to decrease the number and severity of falls.
Design: A literature review revealed fall assessments have low sensitivity and specificity. Few patients are excluded from being “at risk.” To corroborate this, nursing students completed our existing fall assessment tool for 50 randomly selected patients. Indeed, 95% of the patients were at risk for falls.
Population: Based on literature which postulated that caregivers exert influence on outcomes through control of environment, risk assessment and implementation of evidence-based interventions, we implemented a Fall Prevention Program aimed at ALL patients.
Concept: This philosophy differed from our former approach, which focused on preventing falls for high risk patients. Our root cause analyses showed many of our most serious falls occurred for patients not considered high risk.
Methods: Multiple strategies were initiated, including the appointment of assistive personnel as “Fall Coordinators” to evaluate intrinsic and extrinsic fall risk factors at prescribed intervals and report findings to co-workers. Falls were reported using a Fall Event Report, which included fall history, location, level of injury, prevention interventions, mental and mobility status and medications taken within the past 24 hours and trends identified for prevention. This information was analyzed for trends.
Findings: The number of severe falls decreased from 16 (rate of 0.08) in calendar year 2000, to 5 (rate of 0.025) in calendar year 2001. This represents estimated savings of $136,312.
Conclusions: Evidence revealed the absence of a valid, reliable tool to predict risk for falls, contrary to current practice throughout the country.
Implications: This study showed a decrease in the number and severity of falls when all patients were considered at risk.
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Sigma Theta Tau International
9 July 2003