Reducing Harm from Falls with Teamwork and Focused Assessment
Sentara Virginia Beach General Hospital
Virginia Beach, Virginia, USA
Sentara Virginia Beach General Hospital (SVBGH) was a participant in Reducing Patient Injuries from Falls, part of the RWJF/IHI Transforming Care at the Bedside
Suzanne Rita, MSN, RN, Project Leader
Ginni Scharfe, BS, RN, SVBGH Fall Prevention Leader
Irene Selbrede, RN, SVBGH 4E Pilot Unit Leader
Our aim was to reduce patient injury from falls at all Sentara Healthcare Systems hospitals to a rate of no more than one fall associated with moderate-to-severe injury per 10,000 patient days. This report focuses on improvements on the Sentara Virginia Beach General Hospital pilot unit [4E, which cares for medical, surgical, and oncology patients] during the time frame of July 2006 through June 2007.
- Falls associated with moderate-to-severe harm per 1,000 adjusted patient days*
- Falls rate per 1,000 patient days
*The team converted data to “harm per 10,000 adjusted patient days” by multiplying the data by 100.
Our team recognized patients at risk for injury from a fall might be missed when a standard fall assessment was used. To prevent this, we developed a tool to identify patients at risk for harm from a fall: The ABCs High Risk To Harm (HRTH) assessment tool. This was created in collaboration with other hospital teams participating in the IHI Reducing Patient Injuries from Falls initiative.
The pilot unit at Sentara Virginia Beach General Hospital tested the tool and discovered that some patients at risk for harm from falls were not necessarily at greater risk for falling. The team then combined their falls risk assessment with the HRTH tool to assess patients for both falls and risk of injury from a fall. [NOTE: The assessment tool and other tools can be found in Section Four of the TCAB How-to Guide: Reducing Patient Injuries from Falls
Other tested changes included:
The graphs below show hospital-wide data that reflects the spread of the successful ideas that were initiated on the SVBGH pilot unit:
- January 2007: Tested of ABCs HRTH fall injury tool and addition of “high risk to harm” to standardized shift report tool
- February 2007: Safety huddles tested and refined
- March 2007: Fall follow-up process tested and refined; fall expert follow-up tested and refined
- June 2007: Tested safe exit on different pilot unit
Summary of Results / Lessons Learned / Next Steps
The Sentara Healthcare System leaders reinforced their dedication to fostering a culture of safety through their commitment to initiatives to prevent fall-related injury. The steps taken to prevent falls provided a framework for improvements and promoted an environment that encourages critical thinking, one in which all members of the hospital team “have a questioning attitude.” Having a Questioning Attitude is just one of our five behavior-based expectations (BBE). Our other BBEs include: Pay Attention to Detail, Communicate Clearly, Effective Handoffs, and Never Leave Your Wingman. Our culture of safety provided the necessary foundation for improving our fall and fall with injury rates.
Stephanie S. Jackson, RN, MSN, ACNS-BC
Manager, Patient Care Services, Education Department, Diabetes and ET Services
Sentara Norfolk General Hospital