Authors: Lancaster, Ava D.; Ayers, Annette; Belbot, Brenda; Goldner, Virginia; Kress, Linda; Stanton, Donna; Jones, Polly; Sparkman, Lora

Source: Joint Commission Journal on Quality and Patient Safety, Volume 33, Number 7, July 2007 , pp. 367-375(9)

Publisher: Joint Commission Resources

Abstract:

Background: For Ascension Health's Healthcare That Is Safe strategy, eight hospitals served as alpha sites in the program to prevent falls and eliminate falls with injury.

Methods: The alpha sites implemented four key strategies: (1) assessment and re-assessment of patient risk factors for falls, (2) visual identification of patients at high risk, (3) communication of patient fall risk status, and (4) education of patients, families, and staff about fall prevention.

Results: The recommendations of the alpha initiative spread rapidly throughout Ascension Health and preceded measurement of the fall ratio. Even so, a 9.9% systemwide reduction in acute care fall rates from January to October 2006 was observed, and the average rate of falls with serious injury was less than 0.10 per 1,000 patient days. Compared with national rates, falls with serious injury at Ascension Health were less than 10% of the expected rate.

Discussion: Although it is not possible to prevent all falls in acute care facilities, decreasing the number of falls and the risk of serious injury from falls is possible. Key steps caregivers can take to prevent falls and fall injuries include establishing a trusting relationship with patients and their significant others; frequently reorienting patients to their environments, reminding those at high risk of falls not to get out of bed without help; checking on patients frequently and keeping their personal articles within reach; and protecting patients from falls at all entry points into the health care system.

Document Type: Research article

Publication date: 2007-07-01

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