Inpatient falls account for the largest category of reported incidents in hospitals. The National Patient Safety Foundation reports that inpatient fall rates range from 2.3 – 7 per 1000 patient days with 30% of falls resulting in injuries, and 4 – 6% of falls resulting in serious injuries. Several strategies have been implemented within the Spectrum Health Grand Rapids Hospitals over the last year to reduce the impact of falls on patients and families.
An assessment of the Falls/Restraint Committee was conducted by its membership. This assessment revealed the need to:
- Eliminate the dual committee structure,
- Update the falls committee membership to include representation from high fall rate units as well as additional ancillary areas, and
- Begin to build unit-based fall prevention champions using the existing Quality Safety Officer and Safety Coach structure.
The recommended changes to the committee structure were made in the following months.
The first Quality Safety Officer/Safety Coach Fall Champion meeting was held in March of 2014. The content of this meeting emphasized the importance of mobility in the prevention of falls and functional decline. Additionally, information was also deployed through the Quality Safety Officer team related to using the nursing process to assess, diagnose, plan, intervene, and evaluate the care of the fall risk patient -based individual patient risk factors.
Concurrently, Team Butterworth and Blodgett Pride also implemented the “we all KNOW, we all CHECK, and we all RUN” approach to fall protection and prevention. This approach engaged all clinical and non-clinical employees present in patient care areas in fall prevention by asking each employee to:
- Know which patients are at risk for falling,
- Check if patient needs are met and rooms are free of clutter, and
- Run when a bed/chair alarm sounds
Using this strategy has made fall prevention everyone’s responsibility and expanded the safety net for our patients.
Lastly, the Helen DeVos Children Hospital team has been working to develop and implement the JACK and Jill Pediatric Fall Risk Tool. The tool has been showing promise in its ability to identify pediatric patients at risk for falling. A formal study is now underway to validate its effectiveness.
All of this work has made Spectrum Health a leader in fall prevention and protection. It has driven the fall rate to levels well below the national benchmark, and more importantly it has enhanced patient safety.
Kate Ammeraal MSOTR
Beverly Black RN, CCRN
Kate Bredeweg BSN, RN, ONC
Sue Brooks MSN, RN, ACCNS-AG
Jeff Conzelman PharmD
Stephen Essenburg MSN, RN
Terry Hennessy BSN, RN, MHCA
Cara Knapp MSN, RN
Sandy Knight BSN, RN, OCN, NE-BC
Amy Majeski MHA, BSN-RN, NE-BC
Koren May BSN, RN
Glenna Mindling BSN, RN, ONC
Joann Mooney BSN, RN, CPN, CPPS
Molly Nolan BSN, RN, CPHRM, CPPS
Nicole Procter BSN, RN, CMSRN