UAB Synopsis, Vol. 24, No. 28, July 25, 2005

New standards Make Hospitals Measurably Safer

The 1999 Institute of Medicine's landmark report, To Err Is Human: Building a Safer Health System, highlighted the magnitude of deaths and serious injures that can occur in health care. The report emphasized that health care institutions need to recognize errors as complex phenomena requiring organizational change.

Falls are the commonest adverse event occurring in hospitalized patients, with 2% of all inpatients sustaining a fall during a stay. The typical rate is 4 falls per 1,000 patient days, according to UAB geriatrician Cynthia Brown, MD, who is working with the Centers for Medicare & Medicaid Services to address hospital falls. In the United States, the estimated cost of falls was $20 billion in 1995, rising to $32.4 billion by 2020 (Rubenstein, LZ, Josephson, KR, Clinical Geriatrics Medicine. 2002;18[2]:141-158).

The best way to prevent errors is to design safety into the system, Debbie Soniat, RN, University Hospital Quality Improvement (QI) coordinator, says. "How can we predict who is going to fall in an acute care setting? How can we reduce the risk?

"QI recognizes the majority of falls result from a failure of processes, as opposed to individual staff behaviors," she continues. "For example, a QI falls committee at one hospital reviewed incident reports and noted most falls occurred during change of nursing shifts. This observation led to a review of staffing patterns and identification of patient characteristics that may contribute to higher fall rates during shift changes."

A further analysis determined that individuals who fell were either able to ask for assistance but did not want to "bother" staff or were cognitively unable to use a call bell. The data led to changes in staffing patterns, such as staggered shifts and an overlap of nursing assistants during this time. "The fall team realized a follow-up review of fall patterns over the next few months would allow evaluation and possible revision of the policy," committee Cochair Stephanie Burnett says.

In 2004, the interdisciplinary University Hospital Falls Prevention Team convened to track, report, and reduce falls within the hospital. It includes Chair Jacqueline Richardson-Westbrook, RN, Stephanie Burnett, RN, Kimberly Ayers, RN, Cynthia Brown, MD, Faye Elliott, RN, James Johnson, RN, Terry Motes, RN, John Perkins, Sandra Rudolph, RN, Melanie Schultz, RN, Kerry Shapiro, Debbie Soniat, RN, and Tonya Wright.

In addition to a literature review of fall risks, incidents, and interventions, their efforts have included product evaluation, electronic incident reporting, communication among departments, data collection and reporting to a national data base, staff education, and documentation.

The Falls Prevention Team also revised the UAB Falls Risk Standard and developed the 2005 Mandatory Education and Testing Standard for all patient caregivers. Elements of the initiative include previously tested fall reduction strategies, such as assessment of medication effects, signage encouraging patients to call for assistance, attention to elimination needs, addressing environmental issues such as nonskid footwear, and other available technologies, including bed alarms and low-height beds. Increased use of restraints also was examined, although a restrained patient is not necessarily at low risk for a fall, Dr. Brown says.

To test interventions, the Falls Team coordinated a 2-month bed evaluation on 9 South and C7 South that highlighted lowering beds to inches from the floor to reduce risk and impact of patient falls. The team also piloted coded patient identification bracelets on the orthopaedic units to alert staff of fall risk. The group plans to implement these interventions hospital-wide.

In addition, the Falls Team began a review of the electronic incident reporting system related to falls. Members streamlined data input and investigated succinct methods to communicate falls data to department leadership to enhance departmental QI efforts. A new admission assessment database (IPAA) also improved documentation of fall risk assessment during hospital admission.

The PIN screen was revised to include a Fall Risk Alert and escort notification. Communication regarding patients at risk for falls to the escort service has already improved by 25% via the use of PIN notification. Fall risk armbands have added to communication efforts, as well. The Falls Prevention Team is now creating a fall prevention toolkit for departmental distribution.

The team also plans to conduct ongoing surveillance of hospital falls, staying abreast of current trends through continuous literature review and educational consultations to the UAB patient-care delivery team. "Fall reduction is an important problem in patient safety and involves the efforts of everyone in the health care system," Burnett concludes.