1. West of England Academic Health Science Network - launch
Preventing Harm from Patient Falls
South West Quality and Patient Safety Improvement Programme
(Safer Care South West)
Improving Safety in Mental
Health Collaborative
South of England

2. Patient story
“I needed to go to the toilet. I couldn’t find the call bell. I kept calling out for help. Eventually someone came but they went to get a commode and I couldn’t wait. I know I shouldn’t have tried to get out without help. I should have just gone on the sheets in the bed and then I wouldn’t have broken my hip.”
Improving Safety in Mental
Health Collaborative
South of England

3. Situation Within 18 months:
Reduce the total number of inpatient falls by 10%
Reduce the number of serious falls by 20%
Reduce the number of recurrent falls by 20%

4. Background 2 large hospital sites Over 9000 staff Over 1000 beds
Over 65s is the fastest growing group in population of local area
Change in Culture amongst staff

5. Strategic Falls Prevention Group from Ward to Board
Wide membership of engaged staff
Matrons, nursing, Medical, Therapy, Pharmacy, Facilities, Audit, Patients
Executive Sponsor
Pragmatic frontline actions to reduce falls risk on wards
Quality Improvement methodology in developing new tools at ward level

6. PDSA Testing Ramps A P S D
DATA FEEDBACK TO FRONTLINE STAFF: Compliance with form completion
Cycle 1E: Test form on all patients
Cycle 1D: test with 1, 3 then 5 nurses
Cycle 1C: modify form with RAG risk levels
Cycle 1B: Form modified to link directly with key interventions to prevent falls
Cycle 1A: new falls risk assessment form – 1 patient
Process Change PDSA: Testing falls prevention bundle 43

7. Falls risk assessment

8. Bed safety rail assessment

9. Scheduled checking

10. After falls care

11. Visual cues for staff
Involving all staff members and visitors

12. Posters

13. How did we do?

14. Weekly e-audit tool

17. Pull from neighbouring wards

19. Falls Rate per 1000 bed days from January 2011 to August 2013 Pilot Ward

20. Falls rate per 1000 bed days April 2011 to August 2013 Spread Ward

21. Trust-wide Falls Rate per 1000 bed days from April 2012 to August 201327 19

22. Trust-wide Recurrent falls from April 2012 to January 2013

23. What worked
Working with teams on the ward to test and influence the development of interventions that worked for their patients
Regular huddles to keep up the momentum
Resisting “Spray and Pray”
Leadership at every level

24. Our achievements
Implementation of action-focused bundle across 2 large sites across 18 months with sustained improvement
Involved all members of staff in the hospital from Switchboard to phloebotomists
We have reduced serious harm from falls in our Trust by 30%

25. Next challenges Focus on acute confusion assessment of patients
Improvement work on medical assessment of falls by junior doctors
Measuring blood pressure accurately to identify postural hypotension
New hospital!

26. Recommendation Identify a pilot area with engaged staff
Ensure you have baseline data for process measures before testing
Get the right team together
Set up measurement system early
Don’t spread until you have reliable and sustained improvement