1. Development and implementation of a multidisciplinary fall prevention plan within an inpatient behavioral health unit
Nicole Van Kampen, BSN, RN
Ferris State University and Holland Hospital
Purpose
Failure Modes & Effect Analysis
Results
Future Considerations
A patient fall can have a devastating effect on both the patient and an organization
Behavioral health patients hold an enhanced risk for falls
Fall prevention plans have been shown to be effective in decreasing patient falls (Eckes & Smith, 2015)
A quality improvement project on fall prevention was both developed and implemented at Holland Hospital within the inpatient behavioral health unit. This was done as result of an recent increase in falls during the month of January, 2016
Multidisciplinary FMEA was conducted which disclosed current state process and eight risk priority numbers
Top five RPN’s were focused on for QI project
Preliminary data is reflective of a decrease in patient falls by 66% within one month
Improvement in staff engagement
Improvement in staff comprehension related to fall prevention as evidenced by the decrease in falls
Post implementation staff survey is pending
Ongoing chart audits will occur
Organizational tracking of falls to be reported out quarterly at Nursing Quality Improvement meetings
Early engagement with clinical staff
Root cause analysis versus failure modes effect analysis
Disclose “why” early on
Enhancement in unit based time to improve staff comprehension and involvement in initiatives
Potential Failure Mode
Potential Effect
of Failure Mode
How likely is it to occur that updated fall risk information is included in paper report >24hr
Valuable patient fall risk information is not appropriately communicated to help avoid patient falls
Failure to document interventions in Cerner
Avoidable detection of higher fall risks patients and the interventions to provide appropriate care
Failure to update paper report sheet with fall risk information
<24 hours
Failure for staff to be consistent in the allocation of the MORSE fall risk score
Patient fall could occur
Probability of detecting a high fall risk patient could be missed
Failure to complete initial fall risk assessment in Cerner
Failure to identify a high fall risk patient could occur
Objective & Goals
References
Primary goal was to decrease patient falls by 25%, to be achieved by:
An enhancement in the EMR to improve documentation practices
Implementation of an educational endeavor related to fall awareness and changes to the EMR
Hardwiring both awareness & validity of project into the culture
Eckes, J. E., & Smith, L. (2015) Safety solutions: redesigning a falls prevention standard of practice. Nursing Management, 46(11), 7-9.
Next Steps
Assumption of QI project by unit practice team
Monthly reporting of patient falls at staff meeting
Celebration of success
Lower RPN incorporation, if warranted
Monitor the sustainment of success
Plan
A pre-survey was distributed to clinical staff, which established baseline knowledge and deficits
2) Collaborative work with I.S.
3) Organizational administrative support
4) Development of educational content
5) Unit Practice Team and Staff Meetings
6) Champion
7) Real time case reviews
Contact information
Nicole Van Kampen, BSN, RN
Holland Hospital
602 Michigan Avenue
Holland, MI 49423
(616)
RPN #6
Failure to include fall status in recorded report to next shift
RPN #7
Failure to utilize and implement physical interventions
RPN #8
Lack of selection of interventions may be contingent on supply/equipment availability