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Using Tools to Assess and Prevent Inpatient Falls

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Background: Inpatient falls and fall-related injuries continue to be a complex challenge that health care organizations face. Protecting patients from falls and injury and ensuring a safe environment are fundamental to providing high-quality care.

Facing the problem: In June 2000 NorthEast Medical Center (Concord, North Carolina) experienced an inpatient fall rate (6.1 falls/1,000 patient days) that exceeded the internal benchmark (4.1 falls/1,000 patient days). The interdisciplinary Fall Team developed the Fall Risk Assessment tool. Patients were given a fall risk score and were categorized as either low or high risk. Interventions were chosen by the caregiver and became part of each patient's overall safety plan of care.

The next step: Root cause analyses were performed for each inpatient fall to expose possible relationships between assessed fall risks and root causes. For example, approximately 80% of the patients who fell were confused, had gait disturbance, and were attempting to toilet alone. Through use of Failure Mode and Effects Analysis, the team was able to review the fall process in a prospective fashion.

Focus on high-risk inpatient populations: In January 2001 the Fall Team began to focus on preventing falls in this patient population. An action plan for fall prevention was implemented, resulting in a decrease from 67 to 28 falls per 1,000 patient days.

Results: From the team's inception in June 2000 to the first quarter of 2003, the inpatient fall rate decreased from 6.1 to 2.6 falls per 1,000 patient days—a 43% decrease. With increased patient acuity and specialization in care of new and more challenging patient populations, health care organizations must quickly identify patients' fall risks and develop innovative methods to prevent falls.

Document Type: Research Article

Publication date: July 1, 2003

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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