Fall Prevention Program at UCH

Patient Falls: All Inpatient Locations, All Levels of Harm, per 1000 IP Days
(excludes ED, CTRC, CeDAR, PACU, NICU)
3.08
3.41
2.56
2.02
2.70
3.05
3.90
3.13
2.96
2.68
3.15
2.06
2.27
2.03
1.12
1.19
2.26
2.81
2.09
2.33
1.96
2.28
1.55
2.48
0
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3
4
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Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12
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Total Falls
Goal
Unassisted Falls
3.17 Goal
Common Language
Fall: unplanned descent to floor
Assisted Fall:
Unassisted Fall:
NDNQI benchmark:
UCH benchmark goal (from UHC):
Red/Yellow/Green:
5 Ts:
Fall Debriefing/Huddle:
Fall Champion:
PSN:
Fall Screening Tool
Hendrich/Morse adaptation (RWJ link):
Used for inpatient and outpatient
EMU uses specific homegrown tool
Validity reinforced by MD team last year
For OB want to move to:

Best Practices
Fall Huddle: Reporting/accountability
Fall Champion engagement/Multi-disciplinary
practice/Case study review
Med Surg Manager engagement: Fall Steering
Improving Awareness-Hospital wide Reports/Fall
Summit/OPIT/# of days since last fall.
Bed alarms/Audits
Fall Risk Banner-to all staff on EPIC
Performance reviews: Unit falls affects each individual
evaluation
Culture change: EVERY Fall is preventable


Failed Initiatives
Mobility Signage
Staff Accountability forms/Patient contract
5 Ts/Hourly Rounding
Delirium assessment in med surg areas
Unit action plans
MD engagement
Fall SWAT team
Specific unit plans-Best Practices
Volunteer audits
Knee immobilizers on nerve block patients
Added safety assessment on EMU patients
Gait belt training on Geriatric unit
Post epidural assessment on Post-partem
Adjustment of risk assessment rating on all patients. (reduced
score to be Red)
Added Chemo to fall score
Automatic commode for every Red patient
Mock Bed Alarms
Signage instructing patient on why they are a high fall risk/what
it means for care.
Policies, Bundles, Resources
Fall Policy
No Bundles
No designated resources
THANK YOU!!
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