Madison Patient Safety Collaborative

Making Madison the safest place to receive healthcare

Patient Falls Initiative - Assessment and Identification of High Risk Patients

It was thought that all patients were being assessed for fall risk and then identified appropriately based on their status, per hospital policies. When reviewing fall incident data, it was realized that some patients appeared to have not been assessed for fall risk or at least did not appear to be identified as being at risk for falls. This shared revelation illuminated the need to focus on this essential aspect at the ‘front end’ and improve the portion of patients assessed and identified as being at risk for falls.

Baseline audits at one organization suggested that documented compliance with patient assessment for fall risk was as low as 33%. Actual assessment could have been higher, but not documented in the patient chart.

Great effort was expended to further educate staff on the tools and frequently remind them of the requirement to assess the patient for fall risk and document the event in the patient chart.

It was felt that face-to-face education achieved the greatest result. All hospitals increased their emphasis on assessment for falls risk as part of their overall intervention strategy.

An extremely valuable learning generated by this initiative was the need to focus on improving the assessment of patients for fall risk and then communicating these patients’ fall risk status.

Outcomes:

All hospitals use a fall risk assessment tool in the patient admission profile.
Assessment is performed daily, each shift and with change in patient condition.
High risk patients are readily identified per established procedure, i.e. ‘falling star’ picture by the room entrance or designation on the identification bracelet and chart.
Hospitals have defined ‘order sets’ denoting interventions for patients that are found to have high fall risk.
For one hospital, documented patient assessment for fall risk on admission is up from around 33% to about 90%.
The aggregate percent of fallers that had previously been designated as high fall risk is now over 95% from 42%.