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RML Specialty Hospital
FALL PREVENTION
PROGRAM
NATIONAL NALTH WINNER
2006 for BEST PRACTICE
OPPORTUNITY FOR
IMPROVEMENT
 Patient falls are recognized as a National Public
Health Problem as well as a JCAHO National Patient
Safety Goal
 In 2004 RMLSH experienced an increase in the
number of patient falls
 A multidisciplinary Performance Improvement team
was formed to examine the process & develop a new
approach
 Initial findings revealed the popular assumptions
regarding patient falls were not relevant to our
patient population. Patients were falling most
frequently on the day shift attempting to be more
independent.
PI TEAM ACTIONS –
A NEW APPROACH
 Fall risk assessment begins prior to admission by
Intake Liaisons
 A Safety Risk assessment done on admission & every
shift by RNs, PCTs, RCPs
 Families receive fall prevention education upon
admission and in patient handbook
 Falls risk discussed at weekly multidisciplinary
patient conferences
PI TEAM ACTIONS –
A NEW APPROACH
 Medications which pose special risks for falls are
flagged in the MAR by Pharmacy
 Rehab Services instruct all homebound patients on
falls prevention and distribute a handout to the
families
 Fall risk is documented on transfer form to another
level of care
MONITORING FOR
COMPLIANCE
Ongoing monitors were established for the following:
 Education and information given to patient/family
upon admission
 Safety assessment completed for every shift by
appropriate disciplines.
 Correct signage on the patient’s door
 Bed in low and locked position when no one was in the
patient’s room
 Number of falls per month
 Number of falls with injuries per month
RESULTS
One year after implementation of the
new process, the fall rate dropped
by 76% with 100% reduction of
falls with injury
MEASUREMENT
45
40
35
30
25
20
15
10
5
0
Total Falls
Falls w ithout Injury
Falls w ith Injury
Pre implementation, 2003
26
24
2
Pre-implementation, 2004
42
34
8
Post-implementation, 2005
11
11
0
NEXT STEPS
MONITOR EFFECTIVENESS OF PROGRAM
 Review Fall Assessment and Prevention documentation
of nursing, respiratory and rehab services for
compliance
 Review all patient falls for opportunities for prevention
 Research equipment and opportunities that assist in
the prevention of falls
 Continuous staff awareness through education
 Share results with the healthcare industry