Falls Prevention at CMDHB (Dos and Don’ts) Simon Kerr Professional Leader Physiotherapy CMDHB Northern Region Health Plan First, Do No Harm

Key problem (we started with A3 problem solving methodology) Approximately 90 falls occur every month in our DHB and 30 patients per month are harmed when they fall. Harm includes bruising, lacerations, skin tears, but approximately 2 patients per month will suffer serious harm (fractures, head injuries and death.) In 2010 there were 28 Serious harm (SAC 1,2) falls, mostly fractures of the neck of femur. Northern Region Health Plan First, Do No Harm

Baseline data Northern Region Health Plan First, Do No Harm

Key changes implemented Creation of MDT Falls Prevention Working Group as part of ZPH campaign. Implementation of internationally recognised risk tool ( MORSE) with an intervention matrix on reverse of the risk assessment tool. Falls prevention training package Non slip socks, hip protectors Falls prevention information leaflet for patients and their families Ongoing analysis/audit of all falls reported where serious harm occurs Regular audits looking at risk assessment compliance and implementation of prevention strategies Specific Falls Prevention campaign on Ward 35 East, MHOP. Invisibeam trial with confused patients Poster campaign as part of overall Zero Patient Harm initiatives Policy and Guideline development Ongoing work with ward areas, CNMs and falls champions to self audit Ongoing liaison with Towards 20/20 Projects for falls prevention with view of future builds. Northern Region Health Plan First, Do No Harm

Outcomes so far Increase in falls reporting, and correct detail Greater learning's from any serious harm falls that occur (e.g Radiology) Reduction in serious harm falls, slowly but steadily. Less recidivist fallers – data easily skewed by one patient though! Change in the nature of falls- less predictable falls, less confused patients falling Northern Region Health Plan First, Do No Harm

Results Northern Region Health Plan First, Do No Harm

Results continued…

Results continued…

Lessons learnt (Don’ts) Don’t present it solely a nursing problem! Don’t judge quality of care on crude falls rates, or panic if there is an increase in one area over a month or two – falls data can be easily skewed. Don’t focus on falls prevention at the expense of autonomy and rehabilitation. Don’t panic if falls rates are slow to drop over the first few years – there are no quick fixes for something this complex, and this often represents better reporting. Don’t forget real falls prevention interventions are what are what are important – not checklists and “box ticking.” Don’t benchmark – especially not serious harm falls! Northern Region Health Plan First, Do No Harm

Dos.. Do get accurate data (not easy!) Do focus interventions on those at most risk of harm should they fall (ABC) – Age, Bone density, AntiCoagulation Do post updates to results regularly and prominently – works best in a localised manner! Do build actions into processes that already work – for example assessment tools into admission packages or care plans. Do try to be resilient – there are doubters and detractors everywhere. It would be very easy to give up at times! Do learn from others, including the doubters and detractors! www.patientsafetyfirst.nhs.uk

Thanks for your time. Any questions? skerr@middlemore.co.nz