News

6 Contributing Factors to Patient Falls and How to Address Them

A report released by the Health Research & Educational Trust outlines how five major hospitals reduced overall falls by 35 percent.

October 6, 2016

Preventing patient falls is a pain point for many hospitals. But, a report released  by the American Hospital Association’s Health Research & Educational Trust offers five hospital case studies that may help others to reduce falls.

The report, Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project saw seven U.S. hospitals use a “robust process improvement approach” consisting of tools from Lean Six Sigma as well as change management methodologies to reduce falls with injury on pilot units within their facilities.

Five of the seven hospitals submitted data from the project and, on average, the organizations reduced the falls with injury rate by 62 percent, which was accompanied by a 35 percent reduction in the overall falls rate. If the robust process approach is applied to a typical 200-bed hospital, staff can expect 72 fewer injuries and $1 million in costs saved, the report states.

The report grouped the top 10 contributing factors for falls into six categories:

  1. Fall risk assessment issues
  2. Handoff communication issues
  3. Toileting issues
  4. Call light issues
  5. Educational and organizational culture issues
  6. Medication issues

The importance of identifying and addressing patient falls cannot be understated. An estimated 700,000 to 1 million people fall in U.S. hospitals each year, with 30 to 35 percent of those sustaining injuries, according to the project report.

Below are brief summaries of the five case studies from hospitals that participated in the project. Read the full report here.

Bassett Medical Center, Cooperstown, N.Y.

The team developed an educational effort across the unit, which included a fall safety document that patients, staff and family members review to assess the patient’s fall risk and steps that staff can take to prevent falls. The 180-bed medical center created a “Call, Don’t Fall” campaign, placing signs in patient rooms as a reminder to call for help before leaving their beds.

Two daily huddles were implemented to address falls associated with toileting. During the huddle, high-risk patients are identified and receive assistance with toileting every two hours.

All these efforts led to a 43 percent reduction of falls in the medical unit. Fall huddles now take place immediately after a fall and weekly team reviews are held to look at trends and take steps to address issues.

Baylor Scott & White Medical Center, Garland, Texas

The unit was already using yellow socks and gowns to identify at-risk fall patients, but after identifying communication as an issue, implemented a specific worksheet for the nurse and primary care technician.

Falls were reported in older men who were not using the call light for toileting. After talking with these patients, it was found that they did not feel comfortable being helped by young nurses, who reminded them of their daughters and granddaughters. For this specific demographic, patients were advised that a male member of the staff would assist them when available.

Educational materials were revised, including the patient acknowledgement form and materials were printed in English, Spanish and Vietnamese, and with a third-grade vocabulary reading level. The patient acknowledgement form includes a 16-item checklist that is discussed between the nurse and patient upon admission to the floor.

Although the medical-surgical unit had a small population regarding falls and falls with injury, the unit was able to use post-fall assessments to identify contributing factors and drill down to root causes. The med-surg- unit has reduced falls with injury and the medical center has spread the solutions and ideas to other units in the medical center.

Kaiser Permanente Zion Medical Center, San Diego

After determining that most falls occurred when patients left their bed without assistance, a unit-based approach was taken that involved full engagement of front-line unit staff, going beyond nursing to include environmental services staff, physicians and others. The culture has shifted to a “no one walks alone” mentality.

Education of families and patients occurs upon admission about the danger of falls, along with hourly rounding during which patients are offered bathroom assistance and help to reposition themselves.

Each shift begins with unit huddles and two hours later, changes and observations are reviewed. A falls committee with membership across the hospital was created to instill ownership in clinical areas.

Memorial Hermann Memorial City Medical Center, Houston

The focus of this study was on its cardiology unit and addressed 16 root causes of fall injuries. An important finding was that the tool used to measure a patient’s risk for falls provided inconsistent ratings and variation in assessment.

Older men were determined to be more at risk for falls and were not aware of their increased risk after hospitalization. The hospital implemented consistent patient education and standardized fall safety messaging, focusing efforts on older patients in the cardiology unit. Post-fall meetings also were implemented to discuss immediate interventions and lessons learned.

The rate of falls on the cardiology unit decreased 50.5 percent during the project, and falls with injuries decreased 49.2 percent. The team made a video of best practices and a checklist of critical steps for patient safety to share with the rest of the hospital.

Wake Forest Baptist Medical Center, Winston-Salem, N.C.

A project team recruited from across the organization determined a set of five root causes to address. After looking at medication management, team members found an opportunity to ensure that patients on diuretics receive their medication at least two hours before bedtime.

The team also confirmed that impaired mobility and impaired cognitive function were key risk factors for falls. The team undertook a successful intervention in the oncology unit that involved routine mobility and activity with an aide, physical therapy focused on balance, and strengthening exercises. The average change from baseline to pilot period showed a 27 percent reduction in falls and a 59 percent reduction in falls with injury.

A video monitoring system was installed to identify high-risk patients, and a video technician monitored as many as eight patients from the nurses’ station 24/7. Patients being monitored had a 16 percent reduction in falls and a 41 percent reduction in falls with injury.