Development and implementation of a multidisciplinary fall prevention plan within an inpatient behavioral health unit Nicole Van Kampen, BSN, RN Ferris State University and Holland Hospital Purpose Failure Modes & Effect Analysis Results Future Considerations A patient fall can have a devastating effect on both the patient and an organization Behavioral health patients hold an enhanced risk for falls Fall prevention plans have been shown to be effective in decreasing patient falls (Eckes & Smith, 2015) A quality improvement project on fall prevention was both developed and implemented at Holland Hospital within the inpatient behavioral health unit. This was done as result of an recent increase in falls during the month of January, 2016 Multidisciplinary FMEA was conducted which disclosed current state process and eight risk priority numbers Top five RPN’s were focused on for QI project Preliminary data is reflective of a decrease in patient falls by 66% within one month Improvement in staff engagement Improvement in staff comprehension related to fall prevention as evidenced by the decrease in falls Post implementation staff survey is pending Ongoing chart audits will occur Organizational tracking of falls to be reported out quarterly at Nursing Quality Improvement meetings Early engagement with clinical staff Root cause analysis versus failure modes effect analysis Disclose “why” early on Enhancement in unit based time to improve staff comprehension and involvement in initiatives Potential Failure Mode Potential Effect of Failure Mode How likely is it to occur that updated fall risk information is included in paper report >24hr Valuable patient fall risk information is not appropriately communicated to help avoid patient falls Failure to document interventions in Cerner Avoidable detection of higher fall risks patients and the interventions to provide appropriate care Failure to update paper report sheet with fall risk information <24 hours Failure for staff to be consistent in the allocation of the MORSE fall risk score Patient fall could occur Probability of detecting a high fall risk patient could be missed Failure to complete initial fall risk assessment in Cerner Failure to identify a high fall risk patient could occur Objective & Goals References Primary goal was to decrease patient falls by 25%, to be achieved by: An enhancement in the EMR to improve documentation practices Implementation of an educational endeavor related to fall awareness and changes to the EMR Hardwiring both awareness & validity of project into the culture Eckes, J. E., & Smith, L. (2015) Safety solutions: redesigning a falls prevention standard of practice. Nursing Management, 46(11), 7-9. Next Steps Assumption of QI project by unit practice team Monthly reporting of patient falls at staff meeting Celebration of success Lower RPN incorporation, if warranted Monitor the sustainment of success Plan A pre-survey was distributed to clinical staff, which established baseline knowledge and deficits 2) Collaborative work with I.S. 3) Organizational administrative support 4) Development of educational content 5) Unit Practice Team and Staff Meetings 6) Champion 7) Real time case reviews Contact information Nicole Van Kampen, BSN, RN Holland Hospital 602 Michigan Avenue Holland, MI 49423 (616)494-4252 nickiw@hollandhospital.org RPN #6 Failure to include fall status in recorded report to next shift RPN #7 Failure to utilize and implement physical interventions RPN #8 Lack of selection of interventions may be contingent on supply/equipment availability