Patient Care Quality and Safety Project

Fall Risk Protocol Determine if patient is a high fall risk-

Conley Scale— (2 times per shift) Score of 2 or higher

Implement Interventions: Identifiers, environmental modifications, education

If needed apply advanced fall precaution measures

Process to Improve Patient Identifier Implementation:

Gown, socks, ID band

Who Will Improve This Process?

The Fall Prevention Team: Nursing, case management, pharmacy,

environmental services, transport, PT, OT, RT, and patient care-techs are all represented

Interdisciplinary team, involving all staff members, rather than only direct-caregivers

Staff education to answer call lights Staff meetings regarding fall protocol Family education

Flowchart

Process Breakdown

Clothing and patient identifiers yielded the lowest percentages of implementation

Advanced data excluded

PDCA -Plan Fall risk bundle Rounding- setting new standards Communication/Education Floor Recognition/ Encouragement

PDCA -Do Once a shift rounding Address during transfer of trust Document check list

PDCA -Check

Implement check list during rounding and document: If required materials and education were

employed Reinforce Clutter-free environment

Decreased incidence of falls unit and hospital wide

PDCA -Act Increase bundle awareness or

implement Ensure completeness of bundle Make rounding specific to fall

prevention Develop new charting template

specific to fall prevention materials Update fall prevention protocol

Questions?