The Center for Patient Safety issues this alert regarding falls based on our data analysis.
Falls are a difficult and long-standing challenge for providers. While the majority of events report no harm, falls continue to result in severe life-changing injury or even death. The CPS recommends you re-evaluate your fall risk program, considering the following best practices:
- Ensure the fall risk assessment tool correlates to the daily workflow and all nurses are trained in appropriate utilization of the tool
- Include all staff (dietary, housekeeping, maintenance personnel also) and physicians in your falls prevention program
- Utilize a standardized communication tool to communicate the patient’s fall risk potential to the entire team
- Make certain the preventative measure match the patient’s risk factors
- Individualize/tailor preventative measures to meet the patient’s needs (i.e. bed alarms are not effective for all patients)
- Include consistent patient rounding as part of your preventative measures
- Implement a quick post-fall huddle process to quickly identify contributing factors that require a system/program change
- Routinely/daily review medications and their effect on each patient’s fall risk potential
This alert is provided to increase awareness regarding the complex considerations required for a successful falls prevention program.
Resources:
http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html
http://www.patientsafety.va.gov/professionals/onthejob/falls.asp
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxman1.html
http://centeronaging.med.miami.edu/documents/Evidence-BasedStrategiestoReduceFallRisk.pdf
http://www.champ-program.org/static/Falls_BPIP.FromHHQIWebsite.pdf
https://www.cdc.gov/steadi/
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