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

2. 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

3. Baseline data
Northern Region Health Plan
First, Do No Harm

5. 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

6. 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

7. Results
Northern Region Health Plan
First, Do No Harm

8. Results continued…

9. Results continued…

10. 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

11. 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!

12. Thanks for your time.
Any questions?