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.