CPS PSO Watch/Alert: Fall Risk

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/