How teamwork can prevent patient falls

Each year there are nearly one million patient falls in U.S. hospitals that result in injury in 30 percent to 50 percent of cases, according to H&HN Daily. In response, 19 hospitals in Nebraska have collaborated on a multi-team system, evidence-based approach to decrease fall risk.

"We had no process, no structures in place to decrease our fall risk," Carol Kampschneider, R.N., vice president of clinical and regulatory services at St. Francis Memorial Hospital in West Point, told the publication. Prior to the collaboration, the critical access hospital only considered falls that resulted in broken bones or head injuries as serious, she said. A simple skin tear was not considered an injury and the hospital didn't do a falls risk assessment when patients were admitted. 

But the hospital changed its approach after becoming involved in CAPTURE Falls (collaboration and proactive teamwork used to reduce falls), a project administered via a grant from the Agency for Healthcare Research and Quality. Prior to its involvement in the project, Kampschneider said St. Francis had a fall rate of 7.31 per 1,000 patient days. Two years later that rate dropped to 1.41 per 1,000 patient days. Today, the hospital is "175 days fall-free," she said.

The program trains interprofessional teams to collaborate and use tools in order to understand risks associated with inpatient falls. "Fall risk is multi-factorial," Katherine Jones, Ph.D., a professor at University of Nebraska Medical Center in Omaha, told H&HN Daily. "What we have to have is team members with complementary skills, not the same skill set."

The "teams of teams" coordinate care; one will run the operational environment while the core team is at the bedside, according to Jones.  In the event of a fall, the teams will conduct a "post-fall huddle" within 24 hours to determine what interventions were in place before the fall and to discuss how they can prevent the patient from falling again in the future.

The post-fall huddles are also "a way for immediate learning where people are really focusing on the processes and the system," Jones said, noting that the program has promoted a true patient safety culture in the organizations.

To learn more:
- watch the H&HN Daily interview

Related Articles:
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Joint Commission protocol reduced patient falls by 35%
5 ways to prevent patient falls
Patient safety report reveals more errors but fewer deaths in Minnesota hospitals
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