Quality Improvement: Falls

United we stand, divided they fall

Analeissa Gutierrez, Heddy Cortijo, Jennifer Mariano, Mary Camille

Salvador, Marvin Berueda, and Samuel John

Clinical Practice Problem: Patient Falls

-

An unplanned descent to the floor

(trash can, door, or other equipment),
WITH or WITHOUT injury to the patient

Most prevalent in-hospital adverse

event (Huey-Ming, 2015.)

Leads to injury, prolonged hospital stay,

increased expenses (among others)

GENERALLY PREVENTABLE!!!!!!

Facts about Falls

Per Quigley (2013)..Cost to Hospital

Per CDC (2016)..Cost to patient

3-20% of patients will experience @ least one

fall
Cost the hospital $3500/fall

2.5 million people are seen for falls

30-51% of these falls will result in some sort

of injury
Cost the hospital $16,000 if two or
more falls occur
Costs to treat patients post fall equal
to up to $1.08 billion per year

As of 2008, Medicare no longer reimburse

hospitals for costs due to injury from a fall

700, 000 patients are hospitalized for falls

Fall risk increase with age

Hip fracture 95% of the time are caused by falls

6-44% of these falls will result in a serious

injury such as subdural hematoma, fracture,
bleeding, or even death
Cost the hospital $27,000

Extended length of stay up to 12.3 days longer

National/State Indicators
3 different indicators:
- Structural: supply, skill, and education of staff
- Process: methods of assessments and interventions, job satisfaction
- Outcome: nursing sensitive, depend on the quantity or quality of nursing
care
The National Database of Nursing Quality Indicators (NDNQI) was established
by the ANA to collect information related to impacts on the quality of nursing
care. NDNQI uses process and outcome for patient falls and patient falls with
injury (injury level).
No real indicators related to patient falls yet.

Institute for Healthcare Improvement (IHI) Quality

Improvement Model
The PDSA cycle guides the test of change to
determine if the change is an improvement.
Plan: Develop an action plan based on the 3
questions.
Do: Take actions to test the plan.
Study: Make refinements to the plan as needed.
Act: Implement the changes in the real work
setting.

Quality Improvement Tools

Cause and Effect Diagrams - To brainstorm the main causes of falls, and the
sub-causes leading to falls.
Check Sheets - To collect data on the quality problem and identify the most
important source of the problem.
Pareto Charts - To plot defects, or causes of defects, graphically.

Examples of QI tools:

Graphing data in a run chart is a good way to visually examine trends in the fall rate.

The Morse Fall Risk Assessment Tool is a quick and simple method
of assessing a patients likelihood of falling.

The fishbone diagram that helps

visually display the many
potential causes or effects
of a problem.

Examples of Causes and Solutions

1. Noncompliant. Patients do not call for nurse assistance

Solutions:

2. The bed-exit alarm is not set

3. The patient is on high-risk medications, new meds
4. The patient assessment was inadequate
5. There was a delayed response to the nurse call bell
6.

Decreased mobility

7.

Devices (faulty, or not using)

8.

Insufficient lighting, vision impairment

9.

Clutter

http://www.healthworkscollective.com/chgbeds/55851/5-major-causes-patient-falls

1.
2.
3.

Patient
Environment
Staff

Based on the analysis of the root cause, make recommendation to eliminate or reduce the risk of the
problem reoccurring. Use at least 3 evidence-based resources to support your recommendation.
3 EBP articles:
1.

2.

3.

Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B.,
... & Ganz, D. A. (2013). Hospital fall prevention: a systematic review of
implementation, components, adherence, and effectiveness. Journal of
the American Geriatrics Society, 61(4), 483-494.
Quigley, P., White, S., (May 31, 2013). Hospital-Based Fall Program
Measurement and Improvement in High Reliability Organizations OJIN:
The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 5.
Center for Disease Control and Prevention, (2016). Important facts about
falls. Center for Disease Control and Prevention. Retrieved from http:
//www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

High Reliability Organization: Safe Reliable

performance
Characterized by
1.
2.
3.
4.
5.

Sensitivity to operations: awareness of surrounding and whats going on

within the hospital
Reluctance to simplify: be as detailed as possible, dont oversimplify
Preoccupation with failure: use what has happened previously to plan for
the future
Deference to expertise: involve all staff, and be open to others thoughts
and ideas
Resilience: be knowledgeable and able to react if falls occur

What the patient can do: Nursing Educate

CALL for assistance

Increase strength and balance through exercise
Keep up with preventative care (ex. Vision and hearing)
Know your medications and possible side effects
Take health advice seriously
Maintain safe environment

No rugs, cords, etc.

Railings, bars to hold on to
Lighting
Keep environment free of objects
Proper footwear
Proper maintenance of household (ex. broken stairs)

What can we do about it?

Fall risk assessment (Morse Fall Scale)

Purposeful hourly rounding (NAs & RNs)
No pass zone! (Answer ALL call lights)
Place call lights within reach
High Risk for Falls door signs, and wrist
bands
Bed-exit alarm
Non-skid footwear
Moving high-risk patients closer to nurses
station
Medication review (side effects)
Update documentation/charting

Data to collect to evaluate effectiveness of the recommendation

To evaluate effectiveness, we will calculate fall rate & fall-related injuries (data). *Fall-prevention practices may also be evaluated.
Step 1: Count
# of falls over given period (e.g. 1-mo, 3-mo, etc.)
# of fall-related injuries (i.e. fractures, sprains, head trauma, etc.) **Definition of injury important to identify; facilities may vary
# of occupied bed days, i.e. census, on unit over given period (e.g. Mar 1 = 20 beds, Mar 2 = 23 beds...Mar 30 = 9 beds calculate 30-day total)
Step 2: Calculate
# of falls

occupied bed days

1000

fall rate (e.g. 4 falls / 590 OBDs is 0.00677966, multiply by 1000 = 6.78% fall rate)

Step 3: Visualize
Graph findings (e.g. run chart)
Step 4: Evaluate
Look at trends (increasing, decreasing, etc.)
*Based on findings, make recommendations (e.g. disseminate info, study data, run root cause analyses, suggestions for improvement, etc.)

References
5. How do you measure fall rates and fall prevention practices?. (2013). Agency for Healthcare Research and Quality, Rockville, MD.
Retrieved from http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html
Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., ... & Ganz, D. A. (2013). Hospital fall prevention: a systematic
review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4), 483-494.
Hinshaw, P. (2011). The National Database of Nursing Quality Indicators (NDNQI): linking nurse staffing with patient outcomes. Arizona
Nurse, 64(2), 6-6 1p.
Huey-Ming, T. (2015). Patient Engagement in Hospital Fall Prevention. Nursing Economics, 33(6), 326-334.
Lara-Medrana, R., Alcazar-Quinones, C., Galarza-Delgado, D. A., & Baena-Trejo, L. (2014) Impact of a fall prevention program in the
internal medicine wards of a tertiary care university hospital. Medicina Universitaria, 16(65), 156-160.
Mantalvo, I. (2015). The National Database of Nursing Quality Indicators (NDNQI). The Online Journal of Issues in Nursing.
Preventing Falls in Hospitals. (n.d.). Retrieved from http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html
Tools and Strategies For Quality Improvement and Patient Quality. (n.d.). Retrieved from http://www.ncbi.nlm.nih.
gov/books/NBK2682/
What are nursing sensitive indicators anyway? American Sentinel, (2011). Retrieved from http://www.americansentinel.
edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway/