Falls Reduction Methodist Hospital of Southern California Arcadia, CA November, 2014 AIM Statement Reduce Falls from 2011 baseline by 40% by December 2014. Falls with injury Baseline = 1.0, AIM = 0.6 by 12/14. Run Chart Next Steps • Conduct a follow-up small test of change on “Falls Contract” based on an analysis of its initial implementation. A B C D Falls with or without injury Baseline = 2.60, AIM = 1.56 by 12/14. • Discuss with Nursing Shared Governance Quality & Patient Safety Council the implementation of “Days between Falls” to promote Falls Reduction as a Patient Safety Initiative and staff engagement. 2014 YTD Performance: Falls with injury = 0.23 Falls without injury = 1.46 Interventions • Continue multi-disciplinary approach to Falls Reduction; monitor for undesirable trends. Team Members Data Source: Comprehensive Data System-HRET as of 09-09-2014 Interventions: • Nursing frontline staff (RNs & CNAs) • Nursing leadership (Med/Surg) • Chief Medical Officer: Dr. Bala Chandrasekhar, MD (A) 4/2012: • Identification of patients who are high risk for falls (Morse Scale). • Pharmacist: Dr. Dorothy Wong, PharmD • Revised SBAR report to include fall risk. • Director of EVS: Debbie Sandberg • Director of Radiology: Dr. Dennis Graham, MD • Initiated use of bed and chair alarms. • Risk Coordinator: Rikki Valade, RN • Incorporated Falls Precaution monitoring in hourly rounding. • Clinical Educator: Alisa Rock, RN • Chief Compliance & Risk Officer: Cari Toneck, RN, MSN • Medication Management: initiated MAR alerts for patients receiving Ambien & Lasix. • Infection Control Coordinator: David Bechley, LVN (B) 9/2012: • Established Physician Champion for Falls/Patient Safety to increase awareness of falls as a safety issue (CMO – Bala Chandrasekhar, MD). • CMO initiated Daily Safety Huddle which includes a briefing of any patient falls, identified root causes & corrective actions by Nursing leaders. (C) 2/2013: • Initiated post-fall debriefings. • Developed and initiated nursing unit-specific call light reports. • Developed and monitored unit-specific rounding logs. (D) 1/2014: • Conducted a small test of change of the “Falls Contract” on 5Tower (Medical Tele/Oncology Unit). Data Source: Comprehensive Data System-HRET as of 09-09-2014 Lessons Learned • Alert to Frontline Nursing staff to monitor the length of time a Falls Precaution patient is out of bed. These patients often need rest periods between standing activities (such as brushing teeth, washing) and close monitoring when seated on commode or in chair. • Frontline RN to include in shift report and in transfer to different level of care if patient has had recent fall with injury and the need to monitor for residual effects and/or complications, such as bleeding. • Risk Manager: Adrienne Gundry, RN • Quality PI Informaticist Assist: Christopher Arzadon, MHA, CPHQ • PI Staff Resources • HQI Falls Harm Elimination Toolkit is available on the HQI website at hqinstitute.org < Tools and Resources. • Questions: Contact Mahsa Farahani, Project Manager, HQI at 916-552-7521, email mfarahani@hqinstitute.org.