Lallie Kemp's efforts resulted in an overall 95% reduction in falls, with zero serious injuries from falls and no repeat falls for the year after implementation compared to the prior year. Looking at Joint Commission and NPSF statistics, Lallie Kemp figured that the national average for falls was around 3.5 falls per 1,000 patient days.
The initiative began in September 2010. The key driver, says Hariel, was staff involvement and attitude toward preventing falls. Accountability, involvement, and education fostered a culture focused on preventing falls.
"We had a couple of repeat falls and we got concerned about it," says Hariel, despite being a bit below the national fall rate. "So we got started on this new patient safety initiative. We wanted to increase staff awareness and involvement."
Hariel and others at Lallie Kemp involved in the initiative began by taking a look at data for the prior year and identifying everyone who was on the unit, including supervisors, when falls occurred. The tactic elicited an immediate response as staff realized they would be held accountable for falls under their supervision.
Small steps and greater accountability
The patient experience began to change as soon as patients arrived.
"We revamped our evaluation of fall risk," says Hariel. They also ensured that physicians' order sheets included a place to indicate risk and that the patients would need assistance out of bed. Patients and families were also educated about the risk of falls.