Mock a Fall - Save a Life

Maryum Abdul-Basir, Dennisha Fuller, George Johnson, Marshe’ Minor, and Kara Natividad
Bon Secours Memorial College of Nursing

Description of the Issue Analysis of the Issue Solution

Hypothesis: If healthcare staff members are provided with annual “falls training” in addition to semi-annual
Macro: ❖ Communication skills checks led by physical therapy, then the units will experience less falls overall.
● Fall injuries ranked top 20th most expensive medical conditions (CDC, 2016)
➢ Updating whiteboards
Evidence: The addition of a mock fall drill as a continuation of training would be beneficial to the reduction of
● Fall rate increased 30% since 2007 ➢ SBAR bedside report with patient involvement falls and improvement of staff knowledge and training. A study was conducted to increase confidence levels
● 30% of adults aged 65 and older fall each year ➢ Schmid score reassessment and emphasis in report and improve nursing performance during medical emergencies (Herbes & Heaser, 2016). For two years mock
● $50B in medical cost (Florence, 2017) ❖ Medication codes were conducted, and data was collected related to confidence levels and response times. The results
of the study indicated that nurses competence levels increased when given the opportunity to practice these
➢ Pharmacy consults for high-fall risk meds → narcotics, anti-convulsants,
○ 75% covered by Medicare and Medicaid essential skills, an increase improvement in nurses response time by 12%, and increased staff appreciation
anti-hypertensives, analgesics, sleep aids, etc. of the opportunity for hands-on practice with the equipment, reinforcing their knowledge and refining their
○ Average hospital cost for fall with injury: $30,000
➢ Evaluate medications and medication reconcilliation medical emergency skills (Herbers & Heaser, 2016, pg. 396).
● 700,000 -1,000,000 inpatient falls each year (AHRQ, 2013) ❖ Education/Training
Logistics: The increase in falls on the given units contribute to the overall desire for implementing better
○ 30-50% results in injury ➢ Reinforce patient education from admit date to discharge
plans for patient safety.
■ Toileting most common contributing factors ❖ Material
With the addition of mock falls there will be an increase in staff education. In order to accomplish this task,
➢ Decrease unneccesary material clutter in room per hourly rounds educational tools will be utilized for both new hires and current staff members.
■ 95% of hip fractures results from falls
➢ If patient is ambulating, disconnect and remove SCD sleeves from legs
● 7 fall deaths per hour by 2030 ❖ Equipment Currently offered:
➢ Continue to utilize volunteer services for equipment checks per each room ● Annual skills fair (chest tube management, PPE doning, glucose qualtity control, etc.)
Micro: ➢ Reinforce gait belt standard when getting a patient up and out of bed ● Online module completion (falls prevention module and assessment)
● St. Francis Hospital Performance Improvement Coordinator reports that the hospital experienced 128 inpatient
falls in the fiscal year of 2018
❖ Environmental
○ 27 falls on the Progressive Care Unit ➢ Environmental checks with hourly rounding: Additions:
PT mock fall trial/station with annual skills fair for all employees
■ 6 falls resulted in injury
○ 23 falls on the Orthopedic Unit Completion of all elements of hourly rounding: PT body ergonomics strengthening/training modifications for new hires
■ 12 falls resulted in injury
● $14,000 Joint Comission per fall with injury
➢ 5 p’s: personal needs (toileting), pain, position, possessions, proximity. Make Stakeholders:
sure to put an emphasis on addressing personal needs and toileting as it is one ● Hospital administration
of the major contributors to falls. During rounding making sure to complete ● Employees
environmental safety check to ensure patient’s room is free from clutter or items ○ Nursing staff

Root Cause that could contribute to falls. ○ Nursing administration

○ Nurse educators
■ Appropriate lighting for patient needs
○ Risk management/Falls champion
■ Ensure patient has all personal belongings accessible at the bedside
○ Physical Therapy
The Progressive Care Center and Orthopedic units at St. Francis have experienced ● An interview conducted on February 7, 2019 with nurses on the ● Patients
a significant amount of falls in the past fiscal year (FY’18). The units appear to lack Progressive Care Unit at St. Francis found that one contributing factor to
continual fall training for staff members and fails to enforce fall prevention education patient falls were “patient’s rooms are small and clutter easily.” Costs: - $36/HR - PT for 2hrs each day
to patients. This multifactorial presence emphasizes the need for continual review - Leadership facilitators for 2hrs (nurse educators)
and adaptation of current fall policies. - Equipment/Supplies (online module, poster board, mannequin, etc.)
- Hourly pay for healthcare member to attend mock trial skills fair
St. Francis fall policies
Timeline: Within one calendar year, the required educational modules and skills fair will be revised and
● Annual online fall prevention module References implemented for all direct care staff members.
● Use of preventative equipment Agency for healthcare research and quality (AHRQ) (2018). Preventing falls in hospitals. Retrieved from ● Initial training to be completed within one month of revised plan implementation.
● New staff orientation https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html ● All training, including skills check off, to be completed within one month of completion of online module.
● “Stay with Me” policy
● Fall Prevention training Centers for disease control and prevention (CDC), National center for injury prevention and control. (2016). Data Collection:
● Dual RN/PCT hourly rounding responsibility Web-based inquiry query and reporting system (WISQARS). Retrieved from ● Fall rates collected by medical data analyst
https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html. ○ 3 months - data analysis, 6 months - identify trends
● Fall Prevention whiteboards
● Collaborative bedside shift report ○ Per unit
Florence, C.,, Bergen, G., Atherly, A., Burns, E., Stevens, J., Drake, C. (2018). Medical Costs of Fatal and Nonfatal ○ Type and severity
Falls in Older Adults. Journal of the American Geriatrics Society. 66(4) 693-698. doi: 10.1111/jgs.15304 ● Outcomes
■ Staff compliance
Herbers, M. D., & Heaser, J. A. (2016). Implementing an in situ mock code quality improvement program. American ● Audits
journal of critical care,25(5), 393-399. doi:10.4037/ajcc2016583 ■ Employee surveys
● Do you feel more comfortable caring for patients at risk for falls?
● Are you better informed regarding the fall policy and protocols?
● Are you more capable of preventing falls on your unit?
■ Patient safety questionnaires scores (use of your RN w/ gait belt, use of grip socks/shoes every
time you got up, rationale for why