1. Quality Improvement: Falls
“United we stand, divided they fall”
Analeissa Gutierrez, Heddy Cortijo, Jennifer Mariano, Mary Camille Salvador, Marvin Berueda, and Samuel John

2. Clinical Practice Problem: Patient Falls
An unplanned descent to the floor (trash can, door, or other equipment), WITH or WITHOUT injury to the patient
Most prevalent in-hospital adverse event (Huey-Ming, 2015.)
Leads to injury, prolonged hospital stay, increased expenses (among others)
GENERALLY PREVENTABLE!!!!!!

3. Facts about Falls Per Quigley (2013)..Cost to Hospital
3-20% of patients will least one fall
Cost the hospital $3500/fall
30-51% of these falls will result in some sort of injury
Cost the hospital $16,000 if two or more falls occur
Costs to treat patient’s post fall equal to up to $1.08 billion per year
6-44% of these falls will result in a serious injury such as subdural hematoma, fracture, bleeding, or even death
Cost the hospital $27,000
Per CDC (2016)..Cost to patient
2.5 million people are seen for falls
700, 000 patients are hospitalized for falls
As of 2008, Medicare no longer reimburse hospitals for costs due to injury from a fall
Fall risk increase with age
Hip fracture 95% of the time are caused by falls
Extended length of stay up to 12.3 days longer

4. National/State Indicators
3 different indicators:
Structural: supply, skill, and education of staff
Process: methods of assessments and interventions, job satisfaction
Outcome: nursing sensitive, depend on the quantity or quality of nursing care
The National Database of Nursing Quality Indicators (NDNQI) was established by the ANA to collect information related to impacts on the quality of nursing care. NDNQI uses process and outcome for patient falls and patient falls with injury (injury level).
No real indicators related to patient falls yet.
Structural indicators include the supply of nursing staff, the skill level of nursing staff, and the education and certification levels of nursing staff.
Process indicators measure methods of patient assessment and nursing interventions. Nursing job satisfaction is also considered a process indicator.
Outcome indicators reflect patient outcomes that are determined to be nursing-sensitive because they depend on the quantity or quality of nursing care. These include things like pressure ulcers and falls. Other types of patient outcomes are related to other elements of medical care and are not considered to be nursing-sensitive – these include things like hospital readmission rates and cardiac failure.

5. Institute for Healthcare Improvement (IHI) Quality Improvement Model
The PDSA cycle guides the test of change to determine if the change is an improvement.
Plan: Develop an action plan based on the 3 questions.
Do: Take actions to test the plan.
Study: Make refinements to the plan as needed.
Act: Implement the changes in the real work setting.

6. Quality Improvement Tools
Cause and Effect Diagrams - To brainstorm the main causes of falls, and the sub-causes leading to falls.
Check Sheets - To collect data on the quality problem and identify the most important source of the problem.
Pareto Charts - To plot defects, or causes of defects, graphically.

7. Examples of QI tools:
Graphing data in a run chart is a good way to visually examine trends in the fall rate.
The fishbone diagram that helps visually display the many potential causes or effects
of a problem.
The Morse Fall Risk Assessment Tool is a quick and simple method of assessing a patient’s likelihood of falling.

8. Examples of Causes and Solutions
1. Noncompliant. Patients do not call for nurse assistance
2. The bed-exit alarm is not set
3. The patient is on high-risk medications, new meds
4. The patient assessment was inadequate
5. There was a delayed response to the nurse call bell
6. Decreased mobility
7. Devices (faulty, or not using)
8. Insufficient lighting, vision impairment
9. Clutter
Solutions:
Patient
Environment
Staff

9. Based on the analysis of the root cause, make recommendation to eliminate or reduce the risk of the problem reoccurring. Use at least 3 evidence-based resources to support your recommendation.
3 EBP articles:
Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., ... & Ganz, D. A. (2013). Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4),
Quigley, P., White, S., (May 31, 2013). Hospital-Based Fall Program Measurement and Improvement in High Reliability Organizations OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 5.
Center for Disease Control and Prevention, (2016). Important facts about falls. Center for Disease Control and Prevention. Retrieved from

10. High Reliability Organization: Safe Reliable performance
Characterized by…
Sensitivity to operations: awareness of surrounding and what’s going on within the hospital
Reluctance to simplify: be as detailed as possible, don’t oversimplify
Preoccupation with failure: use what has happened previously to plan for the future
Deference to expertise: involve all staff, and be open to others thoughts and ideas
Resilience: be knowledgeable and able to react if falls occur

11. What the patient can do: Nursing Educate
CALL for assistance
Increase strength and balance through exercise
Keep up with preventative care (ex. Vision and hearing)
Know your medications and possible side
effects
Take health advice seriously
Maintain safe environment
No rugs, cords, etc.
Railings, bars to hold on to
Lighting
Keep environment free of objects
Proper footwear
Proper maintenance of household (ex. broken stairs)

12. What can we do about it? Fall risk assessment (Morse Fall Scale)
Purposeful hourly rounding (NA’s & RN’s)
“No pass zone!” (Answer ALL call lights)
Place call lights within reach
“High Risk for Falls” door signs, and wrist bands
Bed-exit alarm
Non-skid footwear
Moving high-risk patients closer to nurses’ station
Medication review (side effects)
Update documentation/charting

13. Data to collect to evaluate effectiveness of the recommendation
To evaluate effectiveness, we will calculate fall rate & fall-related injuries (data). *Fall-prevention practices may also be evaluated.
Step 1: Count
# of falls over given period (e.g. 1-mo, 3-mo, etc.)
# of fall-related injuries (i.e. fractures, sprains, head trauma, etc.) **Definition of “injury” important to identify; facilities may vary
# of occupied bed days, i.e. census, on unit over given period (e.g. Mar 1 = 20 beds, Mar 2 = 23 beds...Mar 30 = 9 beds → calculate 30-day total)
Step 2: Calculate
# of falls occupied bed days fall rate (e.g. 4 falls / 590 OBDs is , multiply by 1000 = 6.78% fall rate)
Step 3: Visualize
Graph findings (e.g. run chart)
Step 4: Evaluate
Look at trends (increasing, decreasing, etc.)
*Based on findings, make recommendations (e.g. disseminate info, study data, run root cause analyses, suggestions for improvement, etc.)

14. References
5. How do you measure fall rates and fall prevention practices?. (2013). Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from
Hempel, S., Newberry, S., Wang, Z., Booth, M., Shanman, R., Johnsen, B., ... & Ganz, D. A. (2013). Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. Journal of the American Geriatrics Society, 61(4),
Hinshaw, P. (2011). The National Database of Nursing Quality Indicators (NDNQI): linking nurse staffing with patient outcomes. Arizona Nurse, 64(2), 6-6 1p.
Huey-Ming, T. (2015). Patient Engagement in Hospital Fall Prevention. Nursing Economics, 33(6),
Lara-Medrana, R., Alcazar-Quinones, C., Galarza-Delgado, D. A., & Baena-Trejo, L. (2014) Impact of a fall prevention program in the internal medicine wards of a tertiary care university hospital. Medicina Universitaria, 16(65),
Mantalvo, I. (2015). The National Database of Nursing Quality Indicators (NDNQI). The Online Journal of Issues in Nursing.
Preventing Falls in Hospitals. (n.d.). Retrieved from
Tools and Strategies For Quality Improvement and Patient Quality. (n.d.). Retrieved from
What are nursing sensitive indicators anyway? American Sentinel, (2011). Retrieved from