Page 9 - April 2020 Ulupono

Chasing Zero Harm: Fall Prevention
By Alicia Hatori, Risk Coordinator
Adventist Health Castle is focused on delivering exceptional care through our steadfast commitment to chasing zero
harm to our patients. One area of focus
is fall prevention. Falls are a common and devastating complication of hospital care, especially in elderly patients. The Agency for Healthcare Research and Quality estimates that 700,000 to 1 million hospitalized patients fall each year. Here are some things to keep in mind:
• As defined by the National Database of Nursing Quality Indicators (NDNQI), a patient fall is an unplanned descent to the floor with or without injury
to the patient. Include falls when a patient lands on a surface where you wouldn’t expect to find a patient.
All unassisted and assisted falls are to be included whether they result from physiological reasons (fainting) or environmental reasons (slippery floor). Also report patients that roll off a low bed onto a mat as a fall.
• Falls with injury, as outlined by the National Database of National Database of Nursing Quality Indicators (NDNQI) are:
❍ None—patient had no injuries (no
signs or symptoms) resulting from the fall, if an x-ray, CT scan or other post fall evaluation results in a finding of no injury.
❍ Minor—resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, bruise or abrasion.
❍ Moderate—resulted in suturing, application of steri-strips/skin glue, splinting or muscle/joint strain.
❍ Major—resulted in surgery, casting, traction, required consultation for neurological (basilar skull fracture, small subdural hematoma) or internal injury (rib fracture, small liver laceration) or patients with coagulopathy who receive blood products as a result of the fall.
❍ Death—the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall).
What fall prevention practices do we have in place?
• Fall assessment. There is no one size
fits all method to preventing falls, however, a key prevention element is the assessment of an individual patient’s risk for falls. Fall assessments are done upon admission to AHCS.
• Individual needs are noted and accounted for in the patient environment including ensuring appropriate assistive devices are in patient rooms (wheelchair, walkers, gait belts, bedside commodes, over- toilet commode)
• Standardized fall prevention tactics are implemented including, patient education to “Call don’t fall,” hourly rounding, no slip socks, “no one potties alone,” bed/chair alarm activation, and use of gait belts, assistive devices and two-person assist as needed.
• A team (multi-disciplinary) approach to ensuring patient is free from harmful falls.
We recognize that sometimes, despite our best efforts, falls happen. What steps should you take if a fall occurs in your area:
• Assist patient to safety and ensure they
are free from injury by performing head
to toe assessment
• Advise charge nurse and or nursing
supervisor and attending physician.
Perform any ordered testing
• Complete ad hoc fall form in EHR, post
fall huddle form (submit to Charge)
and RADAR incident file. (Please report clearly and concisely and add any follow- up that was done)
Why are there so many post fall to do’s? Each fall event is carefully reviewed by Risk and appropriate clinical leadership as part
of our chasing zero harm commitment. Understanding what led to the fall event and having your feedback and suggestions for improvement are vital!
APRIL 2020 - ULUPONO
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