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Take a Second Glance: A Novel Approach to Inpatient Fall Prevention

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Background: An approach to fall prevention was conducted under the assumption that all inpatients are at risk for falls and that all employees within the hospital setting have a role in fall prevention.

Fall Prevention Programs: Northwestern Memorial Hospital (Chicago), a 725-bed tertiary care academic medical center, recently updated a longstanding fall prevention program, "Take a Glance," to standardize and simplify its approach to fall prevention. In the "Take a Second Glance" program, all patients were screened for higher-than-standard fall risk on admission and at least every 24 hours. Standard interventions were recommended and integrated into practice for all patients. The training session for managers provided information, materials, and job aids for staff to facilitate implementation. A reduced number (36 to 13) of interventions were prescribed for fall prevention, and important safety measures were to be incorporated into the patient's plan of care.

Results: A 20% reduction in total falls (p < 0.0001), a 15% reduction in the average hospital fall rate (p < 0.0001), and a more than doubling of the average days between falls with injuries were found when comparing 11 months of data to the previous year.

Discussion: The fall prevention program is now in the control phase after program implementation. Data are monitored closely for variation, and discussions regarding continued rigorous goal setting for further improvements are planned.

Document Type: Research Article

Publication date: June 1, 2004

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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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