AIM Statement Next Steps Run Chart Reduce Falls from 2011 baseline by

Falls Reduction
Methodist Hospital of Southern California
Arcadia, CA
November, 2014
AIM Statement
Reduce Falls from 2011 baseline by
40% by December 2014.
Falls with injury
Baseline = 1.0, AIM = 0.6 by 12/14.
Run Chart
Next Steps
• Conduct a follow-up small test of change on
“Falls Contract” based on an analysis of its
initial implementation.
A
B
C
D
Falls with or without injury
Baseline = 2.60, AIM = 1.56 by 12/14.
• Discuss with Nursing Shared Governance
Quality & Patient Safety Council the
implementation of “Days between Falls” to
promote Falls Reduction as a Patient Safety
Initiative and staff engagement.
2014 YTD Performance:
Falls with injury = 0.23
Falls without injury = 1.46
Interventions
• Continue multi-disciplinary approach to Falls
Reduction; monitor for undesirable trends.
Team Members
Data Source: Comprehensive Data System-HRET as of 09-09-2014
Interventions:
• Nursing frontline staff (RNs & CNAs)
• Nursing leadership (Med/Surg)
• Chief Medical Officer: Dr. Bala
Chandrasekhar, MD
(A) 4/2012:
• Identification of patients who are high risk for falls
(Morse Scale).
• Pharmacist: Dr. Dorothy Wong, PharmD
• Revised SBAR report to include fall risk.
• Director of EVS: Debbie Sandberg
• Director of Radiology: Dr. Dennis Graham, MD
• Initiated use of bed and chair alarms.
• Risk Coordinator: Rikki Valade, RN
• Incorporated Falls Precaution monitoring in hourly
rounding.
• Clinical Educator: Alisa Rock, RN
• Chief Compliance & Risk Officer: Cari Toneck,
RN, MSN
• Medication Management: initiated MAR alerts for
patients receiving Ambien & Lasix.
• Infection Control Coordinator: David Bechley,
LVN
(B) 9/2012:
• Established Physician Champion for Falls/Patient
Safety to increase awareness of falls as a safety issue
(CMO – Bala Chandrasekhar, MD).
• CMO initiated Daily Safety Huddle which includes a
briefing of any patient falls, identified root causes &
corrective actions by Nursing leaders.
(C) 2/2013:
• Initiated post-fall debriefings.
• Developed and initiated nursing unit-specific call light
reports.
• Developed and monitored unit-specific rounding logs.
(D) 1/2014:
• Conducted a small test of change of the “Falls
Contract” on 5Tower (Medical Tele/Oncology Unit).
Data Source: Comprehensive Data System-HRET as of 09-09-2014
Lessons Learned
• Alert to Frontline Nursing staff to monitor the length of time
a Falls Precaution patient is out of bed. These patients
often need rest periods between standing activities (such
as brushing teeth, washing) and close monitoring when
seated on commode or in chair.
• Frontline RN to include in shift report and in transfer to
different level of care if patient has had recent fall with
injury and the need to monitor for residual effects and/or
complications, such as bleeding.
• Risk Manager: Adrienne Gundry, RN
• Quality PI Informaticist Assist: Christopher
Arzadon, MHA, CPHQ
• PI Staff
Resources
• HQI Falls Harm Elimination Toolkit is
available on the HQI website at
hqinstitute.org < Tools and Resources.
• Questions: Contact Mahsa Farahani, Project
Manager, HQI at 916-552-7521, email
mfarahani@hqinstitute.org.