1. RML Specialty Hospital FALL PREVENTION PROGRAM NATIONAL NALTH WINNER 2006 for BEST PRACTICE

2. 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.

3. 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

4. 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

5. 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

6. RESULTS One year after implementation of the new process, the fall rate dropped by 76% with 100% reduction of falls with injury

7. MEASUREMENT

8. 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