Leading Hospital Improvement

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Zero Falls? It’s Possible.


By Anne Kilpatrick, RN, BSN, CSSBB, Black Belt Clinical II
The Joint Commission Center for Transforming Healthcare

Hundreds of thousands. This is the staggering number of patients who fall in U.S. hospitals each year.

In health care, we have long been committed to reducing and preventing patient falls. In fact, call lights, checklists and risk assessments are just a few types of fall-related interventions that we have become well accustomed to over the years. While these interventions have made strides toward improving patient safety, it’s time to start thinking differently about how we approach falls. 

“Achieving zero falls is impossible.” I often hear this when working with health care organizations across the country on their falls prevention efforts. However, achieving zero falls is possible, especially for organizations committed to zero harm. It is these organizations that often take a proactive instead of reactive approach, increasing their chances for success.  

New Falls Studies
Two new studies in the August 2017 issue of The Joint Commission Journal on Quality and Patient Safety demonstrate how such a proactive approach can lead to a reduction in patient falls.

Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): A Patient-Centered Fall Prevention Toolkit,” by Patricia C. Dykes, PhD, RN, senior nurse scientist and program director, Center for Patient Safety Research and Practice, and program director for Nursing Research, Center for Nursing Excellence, Brigham and Women’s Hospital, Boston, and co-authors
The laminated paper Fall TIPS Toolkit (Fall TIPS) provides clinical decision support at the bedside by linking each patient’s fall risk assessment with evidence-based interventions. The authors identified strategies to integrate Fall TIPS into clinical practice, including: 

  • engaging stakeholders by leveraging existing shared governance strategies
  • identifying unit champions
  • holding training sessions for all staff
  • implementing auditing to assess and provide feedback on protocol adherence and patient outcomes

As a result of the strategies, compliance with using Fall TIPS averaged 82 percent and the mean fall rate decreased from 3.28 to 2.8 falls per 1,000 patient-days. The mean fall with injury rate also decreased—from 1 to 0.54 per 1,000 patient-days. The authors conclude that engaging hospital and clinical leadership is critical in translating evidence-based care into clinical practice.

Evaluation of Sensor Technology to Detect Fall Risk and Prevent Falls in Acute Care,” by Patricia Potter, RN, PhD, director of Research (ret.), Patient Care Services, Department of Research for Patient Care Services, Barnes-Jewish Hospital, St Louis, and co-authors
Sensor technology that dynamically identifies hospitalized patients’ fall risk and detects and alerts nurses of high-risk patients’ early exits out of bed has the potential for reducing falls rates and preventing patient harm. The authors implemented the sensor technology in two phases:

  • Phase 1: An innovative depth sensor was evaluated on two inpatient medical units to study fall characteristics.
  • Phase 2: A combined depth and bed sensor system was designed to assign patient fall probability, detect patient bed exits and subsequently prevent falls was evaluated.

The Phase 1 study was previously reported in the Journal. The findings from the current study showed that during Phase 2, the designated evaluation unit had 14 falls after interventions, for a fall rate of 2.22 per 1,000 patient-days—a 54 percent reduction compared with the Phase 1 fall rate. The comparison medicine unit had 30 falls with no interventions—a fall rate of 4.69 per 1,000 patient-days, representing a 57.9 percent increase compared with Phase 1. The authors conclude a fall detection sensor system affords a level of surveillance that standard fall alert systems do not have.

Targeted Solutions Tool®
In addition to the methods and resources highlighted in the falls studies, The Joint Commission Center for Transforming Healthcare’s Preventing Falls Targeted Solutions Tool® (TST®) provides in-depth support to help your organization with its falls prevention efforts. The TST® is an online resource that provides a step-by-step process to assist your organization in:

  •  measuring fall and fall with injury rates
  • identifying and measuring the specific contributing factors that cause falls
  • implementing the Center’s proven targeted solutions for falls prevention that are customized to address the specific contributing factors identified 

My favorite aspect of the TST® is that it recognizes that one size does not fit all. It understands that contributing factors may not only differ from organization to organization, but also from unit to unit within an organization.

Organizations that closely follow the TST® have greatly benefited. Using the solutions included in the tool, a typical 200-bed hospital could potentially reduce the number of patients injured from a fall from 117 to 45 and avoid approximately $1 million in costs annually. Since its launch in 2016, the TST® has been utilized by more than 275 organizations in their efforts to reduce falls rates. Some of these organizations have experienced zero falls for many weeks.

Journey to High Reliability and Zero Falls
One reason so many organizations have found success with the TST® is its incorporation of high reliability concepts, including Robust Process Improvement® (RPI®). RPI® is a systematic, data-driven problem-solving methodology that incorporates tools and concepts from Lean Six Sigma and change management to help organizations identify the contributing factors of patient falls and develop solutions to prevent them.

I encourage your organization to work with the Center on your falls prevention efforts by using the TST and checking out our other related resources, including a falls prevention guide, “Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare,” and ORO 2.0, an online organizational assessment to help guide hospital leadership.

Together, let’s start thinking differently about how we approach patient falls. I look forward to hearing about your organization’s journey to zero. It is possible.