CPS PSO Watch/Alert: Fall Risk

September 21, 2016    |   By: Aimee Terrell

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/

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