A pandemic makes for difficult circumstances to improve processes. Here at MultiCare Deaconess Hospital, we went back to fall prevention basics, conducting a PDSA using established tools and research as a guide. By standardizing, improving and educating around the post-fall huddle process, we saw increased huddle participation, reduced the fall rate and reduced the number of patients that fell more than once during their stay.
Initially, we focused on patients with multiple falls but found that this occurred largely due to a lack of proactive care planning. This led us back to the post-fall huddle process. Because falls can occur for many reasons, it is imperative to have a collaborative approach to discover the root cause of the fall and brainstorm ideas to prevent a repeat fall.
Using our fall prevention committee as our PDSA team, we surveyed stakeholders, created SIPOCs, process maps, fishbone and driver diagrams to determine issues, concerns and barriers. We implemented a test of change to streamline our post-fall huddle form, continuing to use the WSHA format as a guide. We rolled out education as the test of change went floor-to-floor. Taking feedback, we adapted our form multiple times, creating standard work to guide the huddle at bedside.
Process improvement during a pandemic is certainly difficult, but the work of keeping patients safe continues, even in the face of overwhelming strain to our systems.
As National Fall Prevention Month ends, WSHA remains focused on supporting our members, yet is also incredibly proud to celebrate their successes as they focus on fall prevention and patient safety. If you have any questions regarding WSHA fall prevention, please contact Amy Anderson. (Katie Naipo, RN, BSN, Patient Safety Program Manager, Deaconess MultiCare Hospital)