1. Using a Neuroscience Diagnosis as the Patient’s Primary Risk Factor for Falling

2. Darlene Bailey, PCT Leslie Barna, Manager 2 NE William Benedict, MD Barbara Buturusis, Administrative Director Jose Biller, MD Mary Healey, Manager 2 S/2 Neuro ICU Meri Hix, PharmD Corrie Husak, RN Bresha Mc Clain, RN Neuroscience Fall Prevention and Safety Performance Improvement Team Judy Mc Hugh, NQI, Team Leader Lisa Millsap, APN Martina Notovny, PharmD Vikram Prabju, MD Karen Potoki, APN, Karen Potoki, APN, Risk Management Devra Romick, PT Joanne Scharnak, Nurse Educator, Team Facilitator Theresa Schwenkel, RN Liaison Kate Steinhable, Physical Therapy Educator Azucena Uy, RN

3. Opportunity Statement Reduce inpatient falls on the 2 NE Neuroscience Unit and increase staff knowledge related to patient safety

5. Potential Cause of Falls Environment People Materials Patient Decreased Sensorium Patients At Risk For Falls Documentation Clutter Admitting Issues Bedroom Frequent transfers Inappropriate Adm Fast Turn-over IV Poles Chairs Unfamiliar Room Patient Transfers EducationAge PatientStaff History Of Falls (7-13-05, 8-10-05) Over Estimate Strength & Ability Long Length of Stay Staff Communication Lack of Reg Rounds Not Using Equipment Fall Risk (8-10-05) Gait Belt (7-13-05, 8-10-05) Medications (7-13-05, 8-10-05) Elimination Medication (7-13-05, 8-10-05) Cannot reach call light Call light too complicated Family assists patient to bathroom Not Answering Call Lights Plan of Care Not Documented (8-10-05) HX of Falls Not in EPIC (7-13-05, 8-10-05) Flowsheet Fall Section Incomplete (7-13-05, 8-10-05) Call Light Issues Bed Alarm Door Reminder Risk Levels Not on Lost in covers Confusion/Altered Mental Status (7-13-05//8-10-05) Weakness Medication (7-13-05/8-10-05) Balance Gait Postural Hypotension Stroke Don’t Realize They Need Assistance Sundowner Sedation Narcotics Sleepers Post Fall Analysis (1/06) Gait Belt (8-10-05) Confidential: For Quality Improvement Purpose Only Not available 7/05

6. Multidisciplinary Staff Education oNew fall assessment flowsheets oFall extrinsic and intrinsic factors oAppropriate Bed Alarm Use oGait belt use and transfer competency oFall risk associated with neurologic impaired patient oMonthly fall prevention updates Solutions Implemented

7. Neuroscience Safety Awareness Week oFalls in the Elderly oIs Polypharmacy Causing Acute Confusion oTouch Therapy oGuided Imagery oGait Belt Use and Transfer Competency oMassages for staff Solutions Implemented

8. Designed a Level 3 Fall Prevention Interventions oAll neuroscience patients are at risk for falls oIncreased elimination rounds to include mealtime and bedtimes oObserve patient activity ever hour or more oImplemented Bathroom Buddy- staff stays with patient during elimination oBathroom Buddy- nursing staff stays with patient during elimination oPlace patient on a BedCheck Classic bed alarm and chair alarm oConsult pharmacy regarding medications that can cause altered mental status oRepeatedly reinforced limits and safety needs to patient and family oAssign bed that enable patient to exit towards stronger side whenever possible and transfer patient toward stronger side. oProvide comfort rounds- repositioning, back rub with PM care, assisted ambulation before bedtime. oDeveloped Post Fall Assessment Environment Study

9. Neuroscience Safety Awareness Week of September 26, 2005 Monday, September 26, 2005 Monday, September 26, 2005 Message of Touch Massage & Guided Imagery by Fran Glowinski, MPS, OSS 2 Neuroscience Unit 11:00 to 13:00 18:00 to 20:00 Tuesday, September 27, 2005 Tuesday, September 27, 2005 Lunch and Learn -Falls in the Elderly by Dr. Jose Biller Bldg. 105 Maguire, Room 2812. 11:00 12:00 Bed Check Bed Alarm Use Inservice by Bill Saemann, Macon Company 2 Neuroscience Unit 6:00 to 8:00 10:00 to 11:00 18:00 to 20:00 Wednesday, September 28, 2005 Wednesday, September 28, 2005 Seated Back Massage by Loyola Health and Fitness Club Seated Back Massage by Loyola Health and Fitness Club 2 Neuroscience Unit 2 Neuroscience Unit 6:00 to 7:00 6:00 to 7:00 16:00 to 17:00 Posey Restraint Use and Other Restraint Alternatives by Fred Demshar, Posey Company 2 Neuroscience Unit 11:00 to 12:00 14:00 to 15:00 Nursing Performance Improvement Fall Prevention Initiative 2005 Thursday, September 29, 2005 Thursday, September 29, 2005 Lunch and Learn –Healing Touch by Ann O’ Malley, RN., C.H.T.P., EMS Bldg. Room 3284 11:00 to 12:00 Bed Check Bed Alarm Use Inservice by Dick Tedesco, Macon Company Bed Check Bed Alarm Use Inservice by Dick Tedesco, Macon Company 2 Neuroscience Unit 6:00 to 8:00 10:00 to 11:00 18:00 to 20:00 Gait Belt Training by Kate Steinhable, PT, MPT. 08:00 to 09:00 Friday, September 30, 2005 Friday, September 30, 2005 Message of Touch & Guided Imagery by Fran Glowinski, MPS, OSS 2 Neuroscience Unit 6:00 to 8:00 Lunch and Learn –Is Polypharmacy Causing Acute Confusion In Your Patient? by Martina Novotny, Pharm. D by Martina Novotny, Pharm. D EMS Bldg. Room 3284 11:00 to 12:00

11. oDevelop monthly education poster series for Medications Contributing to Mental Status Changes oDesign patient and family safety education to neuroscience population oPartner with the Loyola Niehoff School of Nursing to introduce the Neuroscience Level III Fall Prevention Program into student curriculum oIntegrate fall risk factors and history of fall into the Electronic Medical Record oProduce and videotape Lunch and Learn Safety Programs oImprove patient care handoff utilizing SBAR Situation, Background, Assessment, and Recommendations NEXT STEPS

12. Catching the Safety Culture