Nurses play an integral role in keeping patients safe. Nearly every nurse can recall an incident in which a patient fell, and how devastating this was for the patient, family and for the nurse. A leading cause of injury during hospitalizations in the United States is patient falls. At Stanford Health Care (SHC) we have prioritized falls reduction with noteworthy results.
The SHC Falls Prevention Program uses multifaceted strategies and an interdisciplinary approach; employing both organization-wide and unit/patient population specific approaches. Our program focuses on anticipating antecedents that cause patients to fall and engages patients and families.
SHC has instituted an organization-wide Falls Prevention Committee that monitors fall data, call light data, viewing of falls prevention videos data, and uses storytelling about specific cases to engage staff and promote transparency.
Staff and patient education
Extensive staff education for RNs and non-RN care providers.
Education for patients and family, including a fall prevention video that is pushed to every patient via Skylight TV within four hours of admission.
Use of visual tools to identify patients at risk: yellow socks, door magnets, and magnets on patient locater board.
Bedside report, engaging patients and families in safety discussions.
Keeping within arm's reach of fall risk patients while toileting.
Post fall huddles and completion of detailed Huddle Sheet.
Purposeful hourly rounding while closely monitoring patients voiding patterns and fluid intake.
Shortened pajama length to prevent tripping.
Unit-based/patient population specific strategies
Monthly meetings with high-fall units with Falls Prevention Committee Chair and Director of Research to:
Develop unit/population-based action plans.
Hold units accountable for a falls rate below the Collaborative Alliance for Nursing Outcomes (CALNOC) 25th percentile for six consecutive months.
Review every incident of a fall and discuss alternate prevention strategies.
Examples of unit-based strategies:
Developed extensive training materials for Traveler nurses.
Created EPIC reports for nursing assistance with fall risk score.
Early Mobility evidenced-based practice project.
Falls "reflection tool" completed by the nurse whose patient fell, who interviews two colleagues about their fall assessment, prevention strategies and documentation.
Patient contract to always call for the nurse.
Various strategies to enhance teamwork.
Yellow blankets for fall risk patients.
2012 showed an 18% decrease in falls from 2011, with several units realizing over 40% reduction in falls.
2012 falls/1000 patient days was reduced 1.74 hospital-wide, which approaches the top decile when compared to benchmark.