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Patient Safety Tip of the Week
April 18, 2023 Falls Missed Opportunities
Youve all seen it. A patient falls in the hospital. Nursing
staff calls the physician on-call to examine the patient and the patient is
often sent to radiology for imaging studies to rule out a fracture or to CT
scan to rule out a subdural hematoma. Ascertaining the reason for the fall is
often only an afterthought and often neglected all together. In all the
commotion, one of the most important actions is forgotten the post-fall
huddle. The post-fall huddle often gives you more information about a patients
fall risk than any fall risk assessment tools that are used prospectively to
identify patients at high risk for falls. Sometimes the only clue to the cause
of the fall can be found only around the time of the fall (for example,
orthostatic hypotension may no longer be present a day or so later when someone
finally gets around to looking for it).
But a key component of the post-fall huddle is having a
formal tool, usually in checklist format, that guides staff to ask the right
questions.
Clinicians and nursing researchers at Johns Hopkins Hospital
recently reported on their development and implementation of a best practice,
clinician-informed, standardized post-fall debrief tool (Farley
2023).
They note that a post-fall debriefing process that includes
all available team members in the nursing unit facilitates shared ownership of
patient outcomes, promotes more profound reflections of fall events, provides
real-time education, and allows for the implementation of time-sensitive solutions.
Importantly, they note that inclusion of the patient and patients family or
care partner in the group discussion enhances understanding of their experience
and perception of the event.
Prior to this QI project, the hospitals inpatient units were
using 9 different post-fall debrief tools and collected more than 130 data
points when combined. So, standardization was highly desired. They began with a
pilot intervention on 3 adult units during the COVID-19 pandemic from November
2020 to August 2021. Those units were chosen because they had already bought
into post-fall debriefs and only the data collection approach was new.
Their interdisciplinary QI team included participants from
nursing specialty areas of medicine, pediatrics, psychiatry, oncology, physical
therapy, occupational therapy, clinical quality, and risk management. They
first reviewed the 9 existing tools and best practices in the literature on
falls. They considered patient factors (eg, use of antihypertensives,
sedatives, or laxatives, poor understanding of limits), communication factors (eg, staff-to-staff communication, patient education), and
environmental factors (eg, floor condition, lighting,
physical obstacles) that may have contributed to or prevented a fall as they
developed the tools questions.
With input from all the participants, they developed a tool
that incorporated items felt by the group members to be most important and
eliminated overlapping tools and questions. Implementation began on the 3 units
noted above. Through several re-piloting and PDSA cycles over 5 months, slight
changes were made to the tool based on the post-fall debrief report reviews.
Two revisions refined the tool to a total of 13 questions
to assess the fall prevention and medical equipment/devices that were in place
before the fall event and any contributing factors to the fall such as
patient/staff, communication, environmental factors, or issues with safety
features. The average reported time to complete the tool was less than 10
minutes. Further suggestions were to shorten and simplify each question.
Clarifications were also made on timeliness of tool completion and what staff
should be involved in the post-fall debrief. Fall unit clinical champions
also suggested adding a staff-to-staff communication choice to the fall risk
communication during handoff questions.
The pilot project was subsequently implemented organization-wide
in the electronic form as a standardized
post-fall debrief tool. That final tool is quite comprehensive and
addresses patient-related factors, equipment factors, environmental factors,
communication issues, and staffing issues. It ends with a question How can we
prevent this fall from happening again? It also includes something we always
include in any root cause analysis we do what did we do well?. Our one
lament is that it fails to include the one item we have always said is missing
from these post-fall assessments formal assessment for orthostatic
hypotension. In our many columns on falls and in our August 23, 2022 Patient Safety Tip of the Week Yes, There is a Proper Way
to Assess Orthostatic Hypotension we describe the proper way to assess for orthostatic hypotension. It is
important to do this assessment immediately after the fall because by the next
day the patient may no longer have orthostatic hypotension, depending upon the
etiology of the orthostatic hypotension.
Having a standardized post-fall assessment checklist or tool
is highly desirable. This was a nice QI project that other organizations should
emulate. Success factors for the project included strong leadership, having
clinical champions, and strong nurse manager support. Not mentioned
specifically, a shared vision that a simplified standardized tool would be
valuable undoubtedly was also a success factor.
Some of our prior
columns related to falls:
·
April 16, 2007 Falls
With Injury
·
July 17, 2007
Falls
in Patients on Coumadin or Heparin or Other Anticoagulants
·
January 1, 2008 Fall
Prevention
·
October 7, 2008 Lessons
from Falls....from Rehab Medicine
·
November 18, 2008 Ticket
to Ride: Checklist, Form, or Decision Scorecard?
·
August 4, 2009 Faulty
Fall Risk Assessments?
· September 22, 2009 Psychotropic Drugs and Falls in the SNF
· December 22, 2009 Falls on Toileting Activities
· January 2010 Falls in the Radiology Suite
· June 2010 Seeing Clearly a Common Sense Intervention
·
May 29,
2012 Falls, Fractures, and Fatalities
· June 5, 2012 Minor Head Trauma in the Anticoagulated
Patient.
· January 15, 2013 Falls on Inpatient Psychiatry
· March 2013 Sedative/Hypnotics and Falls
· December 3, 2013 Reducing Harm from Falls on Inpatient
Psychiatry
·
June
2014 New Glasses and Fall Risk
· July 8, 2014
Update: Minor Head Trauma in the
Anticoagulated Patient
· August 2014 Cataract Surgery and Falls
· November 4, 2014 Progress on Fall Prevention
· March 2015 Another Paradox: Falls Due to Walking Aids
· June 9, 2015
Add This to Your Fall Risk Assessment
· July 28, 2015
Not All Falls Are the Same
· October 2015 Patient Perception of Fall Risk
· October 27, 2015 Sentinel
Event Alert on Falls and View from Across the Pond
· February 16, 2016 Fall
Prevention Failing?
· March 14, 2017 More
on Falls on Inpatient Psychiatry
· July 2017 Mobility
vs. Falls
· February 2018 Global
Sensory Impairment and Patient Safety
· February 20, 2018 Delirium
and Falls
· March 2019 Newborn
Falls
· July 2019 Increasing
Mortality After Falls in Elderly
· January 14, 2020 More on Newborn Falls
· June 16, 2020 Tracking Technologies
· October 2020 Pre-op Testing Before
Cataract Surgery Leads to What?
· August 23, 2022 Yes, There is a Proper Way
to Assess Orthostatic Hypotension
· September 13, 2022 Smart Socks and Robots for
Fall Prevention?
· November 22, 2022 The Apple Watch and Patient
Safety
· November 29, 2022 Preventing Newborn Falls
· February 2023 Dementia and Risk for
Falling
Some of our prior columns stressing orthostatic
hypotension and falls:
· April 16, 2007 Falls with Injury
· January 15, 2013 Falls on Inpatient
Psychiatry
· February 16, 2016 Fall Prevention Failing?
·
March
14, 2017 More on Falls on Inpatient
Psychiatry
· August 23, 2022 Yes, There is a Proper Way
to Assess Orthostatic Hypotension
References:
Farley H, Stepanek M, Aquino C, et al. Creating a
Standardized Post-Fall Debrief Tool: A Quality Improvement Project. Journal of
Nursing Care Quality 2023; 38(2): 120-125
The tool itself
http://links.lww.com/JNCQ/B43
Print PDF version
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