Reducing Rate of Patient Fall Incidences in a Multispecialty Hospital Through Patient

Tailored Fall Prevention Plan and Intervention

_____________

I. Project Introduction

The major focus of this project is on patient safety by reducing the rate of incidence of
preventable fall among the patients admitted in the in-patient department of the hospital through
early identification of patient at high risk for fall, implementing patient tailored fall prevention
strategies and intervention and continuous patient and family education.
The minor focus of this project in on improving the quality of care and enhancing patient
satisfaction by avoiding unnecessary interventions related to post fall patient care.
II. Problem Statement

Falls represent a leading cause of preventable injury. Hospitalized patients are at an increased
risk for falls, which may result in serious injuries, such as hip fractures, subdural hematomas, or
even death.
WHO describe falls as the second leading cause of unintentional injury deaths worldwide. An
estimated 684 000 fatal falls occur each year. The financial costs from fall-related injuries are
substantial. According to Joint Commission International (JCI), between 30 to 35 percent of
patients who fall sustain an injury. Each of these injuries, on average, adds 6.3 days to the
hospital stay. Costs of serious episodes of injury range from $19 376 to $32 215 (2019 USD).
Centers for Medicare & Medicaid Services (CMS) has identified fall as a preventable event that
should never occur and does not provide reimbursement for the injuries resulted form the fall.
From the period of January 2021 to September 2021, Quality and Risk Management
Department of Dr Bakhsh Hospital has received a total of 33 incident report about patient fall
which is 2 falls per 1000 patient days whereas in year 2020, rate of patient fall was 0.2 fall per
1000 patient days.

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The rate of patient fall with injury of the year 2021 is 0.35 per 1000 patient days.

III. Learning Community

Key Stakeholders – Patients and their representatives, Executive leaders, Nursing staff, Social
worker, patient educator, Quality and risk management staff.
Project Sponsors – Chief executive officer, Chief Medical Officer, Nursing Director, Quality &
Risk Management Director.
Project Leader – Assistant Nursing Director, Patient safety specialist.
Team Member – Staff nurses, Nurse Unit managers, Patient educators, Resident physicians
and Quality coordinator.

IV. Aim
The aim of this project is to reduce rate of incidence of patient fall from 2 falls per 1000 inpatient
days to 0.2 fall event per 1000 inpatient days within 6 months.
Scope:
In-scope – All patients above 12 years of age admitted in the in-patient department.
Out-scope: All patient below 12 years of age, out-patient department, Day case unit.

V. Proposed Intervention

The project will be based on the learning health system framework and quality improvement tool
PDSA will be applied for the improvement process.

In the data to knowledge (D2K) phase of Learning Health System cycle we identified several
causes for the increase in patient fall event by conducting root cause analysis and brainstorming
sessions with a multidisciplinary team of nurses, housekeeping staff, social worker, educators
and safety officer

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Main causes were identified using multi-voting technique and solutions were recommended

Primary intervention:
In knowledge to practice (K2P) phase of Learning Health System cycle, quality improvement
tool, PDSA shall be used to apply a patient centered fall prevention tool kit developed by
Agency for Healthcare Research and Quality AHRQ – Patient Safety Learning Lab known as
“Fall TIPS” (Tailoring interventions for patient safety).
Plan Do Study Act (PDSA)

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Plan:
 The team will identify fall TIPS champions.
 Project SWOT (Strength, Weakness, Opportunities and Threat) and GAP analysis will be
done.
 Training will be conducted for fall champions, staff nurses, patient care assistant, patient
educator and housekeeping staff.
Do: Project will be implemented in three phases
 1st pilot test will be conducted for four days using one patient, one nurse from one unit
(Surgical) (1st November 2021 – 4th November 2021).
 The assigned nurse shall perform patient fall assessment using Morse Fall Scale at
patient’s bedside and ensure patient and family involvement.
 After completing the assessment, the nurse will complete the Fall TIPS poster hanged at
patient bedside by discussing the risk and matching interventions with the patient/family.
Study:
 The pilot test shall be audited by the fall champions. Following are the elements of audit:
 Is the patient's Fall TIPS poster updated and hanging at the bedside?
 Can the patient/family verbalize the patient's fall risk factors?
 Can the patient/family verbalize the patient's personalized fall prevention plan?
 After 1st pilot testing, team meeting will be held to identify the barriers and challenges
and the recommended solutions will be implemented in 2nd phase of project.
Act:
 2nd phase of the project will be implemented for two weeks for all the patients admitted in
the surgical unit from 7th November 2021 to 21st November 2021.
 Auditing will be done by fall champions every third day i.e. 5 audits will be done. The
data shall be analyzed and presented in the team meeting. New barrier and challenge
will be addressed in the meeting and solutions will be implemented.
 Final phase (3rd phase) of the project shall be for 4 months starting from 28th November
2021 to 30th April 2022. In this phase all the admitted patients in the surgical, medical,
OB/GYN and ICU department will be included. Monthly team meeting will be held to
identify the challenges faced during the implementation of the project.
Secondary Intervention:
 Daily rounds (per shift) shall be done by the nurses ensure that the bathroom floors are
not wet.
 Quarterly safety rounds shall be conducted by the facility safety officer/patient safety
specialist to identify risks for fall and implement mitigating actions for the identified risks
 Reporting any fall event to the QRM department and In-depth investigation of all fall and
implementation of corrective action

VI. Measurement

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In the practice to data phase of learning health cycle (P2D), auditing will be done by fall
champions every third day on each unit using the Fall TIPS audit tool.

Measure Type Data Source Target

No. of Audits per month in each unit Process Audit Form 10
Percent of patients for whom a fall risk Process Medical record 100%
assessment along with fall posters was review
completed within 4 hours of admission
Percent of patients with a tailored Fall TIPS Process Audit Form 100%
poster hanging above their bed

No. of patient fall /1000 inpatient days Outcome Incident reporting 0.2

No. of patient fall with injury/1000 inpatient Outcome Incident reporting 0.2
days

Percentage of patient who verbalized their Outcome Audit Form 90%

risk factor

Percentage of patients who verbalized Outcome Audit Form 90%

their fall prevention plan

No. of bathroom without grab bar Structure Safety rounds 5%

No. of rooms with no emergency call bell Structure Safety rounds 0%
No. of rooms with non-functioning bedside Structure Safety rounds 0%
call bell

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VII. Challenges

Potential barriers Strategies

For implementing Fall TIPS toolkit
Unavailability or delay in the availability of Before starting the project, create a project
resources required such as printed and charter and budgeting plan for the resources
laminated posters, Markers and board wipers and get approval from higher administration.
Put in the early request for the purchasing of
required resources
High turn-over rate of nursing and other Include fall TIPS training as part of hospital
hospital staff wide and departmental orientation program
Language barrier – Some staff might not To involve patient educators, Social worker
speak the same language as understood by and patient care assistant in educating the
the patients (as most of the nursing staff are patients about their fall risks and fall
English speaking and patient are Arabic prevention plan using Fall TIPS posters
speaking)
Fall champions/unit managers not completing Continuous training for fall champions and
required no. of audits recognitions for completing audits
Weak Wi-Fi Signal preventing nurses from Conduct fall risk assessment on printed copy
conducting bedside fall risk assessment using of Morse fall scale and latter enter it in the
Morse Fall Scale system
For secondary intervention
High cost related to structural changes such Conduct cost benefit analysis which will be
as installing grab bars/uneven floors at the presented to the higher administration

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 entrance of bathrooms identifies during safety
rounds
Underreporting of patient fall incidences Encourage incident reporting by showing
commitment to just culture by the higher
administration.
In-service and hospital wide lecture on
importance of incidence reporting

VIII. Sustainability

Fall TIPS toolkit is a three steps implementation process. The first step i.e. the assessment of
fall risk by using Morse Fall Scale is already the part of initial nursing assessment at the time of
admissions for all inpatient admissions but is not done at bedside due to weak Wi-Fi signals in
patients’ room. With the availability of laptop and enhanced Wi-Fi connection the assessment of
fall risk at the bed side (for patients’ involvement which is an integral part of this project) can be
done easily. The next step which is completing the Fall TIPS poster is the new step and will
require certain actions to ensure sustainability of the process.
 Incorporating Fall TIPS training as a part of hospital wide orientation and departmental
orientation.
 The hospital has a current system of Daily Grand Round where the hospital executives
makes round in all wards to identify patient satisfaction/dissatisfaction and complaints.
Checking the completion of Fall TIPS posters can be included as one of the activities
during the rounds.
 Units that achieve the target for rate of fall incidence shall be recognized in Hospital
executive committee meeting with patient safety champion certificate
 The success of the improvement project will be advertised and publish on hospital
website and Bakhs.info.

IX. Scalability

If this improvement project is successful and we are able to reach the target, the Fall TIPS
posters can be implemented in other hospitals in-patient departments. For scaling up, the
Institute for Healthcare Improvement’s Framework for Spread shall be used.
Leadership – The proposal will be submitted to the Board of directors and team will be
assigned.
Set-Up for Spread: All stakeholders shall be identifies and involved in the project. They will be
given education and training about the toolkit and shall be involved in the pilot testing.
Better Ideas: Fall assessment will be done using Morse Fall Scale and bedside fall tips poster
shall be implemented.
Communication: Consistent, sustained message about the success and challenges shall be
spread across the organization though nursing administration meeting, executive committee
meetings and newsletters.
Social System: Focus group interview and staff satisfaction survey will be done for all
stakeholders to identify cultural, social and educational barriers
Knowledge Management: Spread the knowledge through board sponsored patient safety
seminars and workshops
Measurement and Feedback: Organization wide reporting of patient fall and patient fall with
injury through incident reporting system. Unit based auditing of adherence to toolkit and patient
engagement

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X. References

 World Health Organization ,Newsroom /fact sheets – 26th April 2021

 How Much do Patient Falls Cost in Your Medical Facility, Market Scale – 15th Oct 2020
 Dykes, Patricia & Carroll, Diane & Hurley, Ann & Gersh-Zaremski, Ronna & Kennedy,
Ann & Kurowski, Jan & Tierney, Kim & Benoit, Angela & Chang, Frank & Lipsitz, Stuart
& Pang, Justine & Tsurkova, Ruslana & Zuyov, Lyubov & Middleton, Blackford. (2009).
Fall TIPS: Strategies to Promote Adoption and Use of a Fall Prevention Toolkit. AMIA ...
Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2009. 153-7.
 Agency for Healthcare Research and Quality (2013). Preventing falls in hospitals: How
do you measure fall rates and fall prevention practices? Retrieved from
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html
Avanecean, D., Calliste, D., Contreras, T., Yeogyeong Lim, & Fitzpatrick, A. (2017)
 Dykes, P.C., Duckworth, M., Cunningham, S., Dubois, S., Driscoll, M., Feliciano, Z.,
Scanlan, M. (2017). Pilot testing fall TIPS (Tailoring Interventions for Patient Safety): A
patientcentered fall prevention toolkit. The Joint Commission Journal on Quality and
Patient Safety, 43, 403-413.
 Tzeng HM, Jansen LS, Okpalauwaekwe U, Khasnabish S, Andreas B, Dykes
PC. Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) Program to
Engage Older Adults in Fall Prevention in a Nursing Home. J Nurs Care Qual. 2021 Jan
28. PMID: 33534349.
 Esguerra, E. (2020). A Patient-Centered Approach to Fall Prevention. [Doctoral project,
University of St Augustine for Health Sciences]. SOAR @ USA: Student Scholarly
Projects Collection. https://doi.org/10.46409/sr.THBW2378
 Carter EJ, Khasnabish S, Adelman JS, Bogaisky M, Lindros ME, Alfieri L, Scanlan M,
Hurley A, Duckworth M, Shelley A, Cato K, Yu SP, Carroll DL, Jackson E, Lipsitz S,
Bates DW, Dykes PC.Adoption of a Patient-Tailored Fall Prevention Program in
Academic Health Systems: A Qualitative Study of Barriers and Facilitators. OBM
Geriatrics 2020;4(2):15; doi:10.21926/obm.geriatr.2002119.
 Bouldin, E. L. D., Andresen, E. M., Dunton, N. E., Simon, M., Waters, T. M., Liu, M., …
Shorr, R. I. (2013). Falls among adult patients hospitalized in the United States:
Prevalence and trends. Journal of Patient Safety, 9(1), 13–17.
 Massoud MR, Nielsen GA, Nolan K, Schall MW, Sevin C. A Framework for Spread:
From Local Improvements to System-Wide Change. IHI Innovation Series white paper.
Cambridge, MA: Institute for Healthcare Improvement; 2006.

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