Implementing an effective falls-prevention program while coping with budget constraints and staff shortages is a challenge for most healthcare facilities. Many such programs focus on accurately identifying risk factors to calculate a fall risk score using a standardized assessment tool, followed by interventions based on that score and identified degree of risk—not individualized risk factors.
Risk-factor assessment and individualized care plans have been shown to be helpful in reducing falls. But healthcare facilities can gain significant insight from timely analysis of individual fall incidents. Implementing a falls-response team can help facilities analyze potential causes of falls specific to the facility, and in turn improve patient safety and quality of care. That’s what we’ve done at The Valley Hospital in Ridgewood, New Jersey, and our hospital-wide fall rates have dropped as a result.
Goals of the response team
Our fall-response team has two major goals:
- To gather data surrounding the circumstances of every fall
- To teach staff, patients, and families about future falls prevention.
Although a tedious task, gathering information that can be analyzed for trends is a valuable aid. At our hospital, for instance, when we find similarities among falls that have occurred on the same unit, we implement education or practice changes. Data analysis from one unit over several months may show that incorrect fall-risk assessment and lack of interventions contributed to the falls. This finding may underscore the need to reeducate staff regarding the facility’s fall-risk assessment tool and interventions.
In their teaching role, response team members become the allies of unit nurses. Responders gather data and review the specific fall with the nurse, patient, nurse’s aide, and patient’s family. Once staff members understand how they could have prevented the fall, many go on to participate in developing an action plan to prevent future falls in similar circumstances. In effect, staff members become part of the falls response team as they discuss possible corrective actions immediately after a fall.
How do you get started developing a falls response team? First, staff time and resources must be allocated, and this requires support from nursing leaders. Our hospital already was using bed and chair alarms, had moved patients closer to nursing stations, and had purposeful hourly rounding. Yet we still struggled with fluctuating fall rates. Several members of the patient safety subcommittee developed a basic framework for a fall response team and then pitched the idea to the Patient Safety Team (PST) and leadership staff. Both groups approved the proposal—and we were on our way.
Choosing team members
Next, we had to choose staff members to serve on the team and act as responders. The team should consist of staff from different disciplines; each one must have an interest in patient safety and be able to respond when circumstances are fresh in everyone’s minds. All must work together within a standardized process focused on one goal: gathering information while partnering with nurses to learn from the fall and prevent a similar occurrence in the future.
Responders should be approachable, open, reliable, and knowledgeable about falls and patient safety. Staff nurses should feel comfortable calling responders. Just as important, nurses must feel confident that team members consider them partners in improving patient safety, not fearful that their honest, open participation may lead to punitive action. (To reduce bias potential, Valley’s process calls for team members who respond to a fall have no affiliation with the clinical unit or department in which the fall occurred.)
As needed, responders also provide education on patient safety to the patient and family. For example, when an elderly patient who has become deconditioned during a prolonged bedrest experiences a fall, teaching both the patient and family about progressive ambulation and exercise during the hospital stay may prove beneficial. With the use of safety interventions and devices, such as chair and bed alarms, providing such education on these interventions and other means of risk prevention can improve patient safety and outcomes.
Essential team members
Members of the fall response team should include advanced practice nurses (APNs), nurse managers, and direct-care nurses. A house physician or APN may assume additional responsibility for injury assessment at the time of data collection.
Because falls may involve both intrinsic and extrinsic factors, an environmental supervisor can be a great resource for the team, helping to identify and quickly correct environmental factors that may have contributed to a fall. For example, a malfunctioning bed alarm might warrant taking the bed out of service and replacing it as soon as possible. An on-site supervisor can ensure a smooth, rapid transition.
A pharmacist is integral to the team. Most falls occur among the elderly, many of whom take multiple medications. Drug interactions, inappropriate dosages, and certain medication classes have a high correlation with falls. For example, benzodiazepines, opioids, and sedatives have been linked to an increased fall risk among elderly persons. A pharmacist who is knowledgeable about polypharmacy risks in older adults and available to conduct a full medication review serves as a valuable member of a fall response team. The pharmacist might recommend changing a dosage or suggest an alternative drug to reduce the risk of sedation or confusion, while educating the nursing staff and patient. The fall response team may use the Beers Criteria as a guide. It identifies medications whose potentials risks in the elderly outweigh their potential benefits. (See http://archinte.ama-assn.org/cgi/content-nw/full/163/22/2716/TABLEIOI20821T2.)
The most important role of the fall response team is completing a post-fall analysis form. Focusing on the Joint Commission’s list of the most common causes of patient falls may help the team create a form that yields valuable data. Significant factors that influence falls include training, staff and patient environmental factors, and communication. If your facility uses electronic medical records, piloting a paper form is a helpful first step, as multiple revisions will be necessary. Focus on key data, which may include:
- age and gender of patients who’ve experienced falls
- what the patient was doing, or trying to do, just before falling
- appropriate fall-risk assessment
- what, if any, preventive measures were in place
- intrinsic and extrinsic risk factors contributing to the fall.
Analysis of our 2008 falls data yielded valuable information about why our patients fell. We found that in 70% of falls, medications (including antihypertensives, sedatives, and opioids) had been given within 4 hours of the fall. Toileting circumstances were the second most common reason for falls.
Regular and in-depth monthly reviews of post-fall analysis data have been pivotal to the success of our falls response team. Only by keeping a close eye on this data and breaking it down by nursing unit were we able to find such trends as a link between falls and commonly used sedatives used to induce sleep; we immediately began staff education to heighten awareness. As an additional reminder of the risk, we incorporated warning messages into our computerized medication administration record and controlled substance-dispensing system.
From our review of completed post-fall analysis forms, we also learned that communication among caregivers needed to be improved; we saw that fall-risk information wasn’t consistently being passed between nurses and nurses and aides. For instance, when I responded to a particular fall, one nurse’s aide told me, “I had this patient yesterday. I knew he was at risk for falling.” Only a few times did I hear that an aide had received report from the nurse that day about a patient’s risk level. This information gave us another chance to review our process for face-to-face report and make sure pertinent information was being shared.
Within a year, not only were we able to develop a fall response team and collect useful data; we also were able to reduce fall rates from 2.9 per 1,000 patient days in 2010 to 2.7 per 1,000 patient days in 2011. Diligent and consistent review of the data allowed us to achieve this significant result. We believe this practice also has heightened staff awareness. Team debriefing after a fall has provided staff with the knowledge they need to better prevent falls.
Chances are your facility already has the basic resources needed to create a fall response team. Together with a creative approach, you can use these resources to develop and implement the team—and move toward improved patient safety.
Lora Bognar is an advanced practice nurse at The Valley Hospital in Ridgewood, New Jersey.
Molony SL. Monitoring medication use in older adults. Am J Nurs. 2009 Jan;109(1):68-78.
Joint Commission. 2011 National Patient Safety Goals. www.jointcommission.org/standards_information/npsgs.aspx. Accessed May 15, 2011.
We have so many falls at our facility. We know they are going to happen because we have a number of patients who are unaware that they can no longer walk and therefore attempt to stand. We watch them like hawks to intervene while they are in the process rather than once the alarm sounds and the bottom is no longer on the chair but we do not have adequate staff, especially when breaks need to be taken, to keep an eye on all at risk. Any suggestions? We are a restraints free facility.
This is just one of a first initiative to having a fall prevention program that identifies a root cause analysis. This does not however, prevent actual falls. In fact, if you are not present in real time, it is more likely than not, you will be present to assist post fall. It is the reality. My recommendations, insist family to participate in fall prevention.