Opportunity Statement

1
Opportunity Statement The 2007 National Patient
Safety Goal 9 B Implement a fall reduction
program and evaluate the effectiveness of the
program 6- West is a 20-bed Adult Medical
Oncology Unit at Loyola University Medical
Center. The unit specializes in the treatment of
hematology/oncology patients requiring
chemotherapy. Patients range from those that are
newly diagnosed, post chemotherapy, symptom
management, neutropenia, and palliative care and
hospice. To comply with the 2007 National
Patient Safety Goal 9 B, 6-West/BMT nursing unit
formed a BEE SAFE Fall Reduction
Multidisciplinary Committee to analyze types of
falls and frequencies of falls as well as
implement several evidenced-based interventions.
The initial fall rate for 6-West was 12.9 per
1000 adjusted patient days for the 1st Calendar
Quarter 06. The committees goal is to keep the
fall rate below the National Database of Nursing
Quality Indicators Adult Medical mean of 4.13. A
reduction in patient falls will reduce the risk
of patient injury. Patient falls hold a potential
for increased morbidity, mortality and economic
loss to the institution on a problem that is
largely preventable. The team used the Rapid
Cycle Plan-Do-Study-Act as their model for
improvement. Data analysis related to falls
identified numerous risk variables. The most
likely causes of inpatient falls on 6-West were
associated with elimination which meant getting
to the bathroom for urgency, diarrhea and
incontinence, mobility or physical impairment
such as muscle weakness or gait disturbance,
mental status changes, and medications that can
cause acute confusion or sedation. Over the
past ten months, initiatives focused on staff
education, environmental safety, bed alarm usage,
and development of a Level III fall prevention
plan. The BEE SAFE Committee had taken a
multidisciplinary approach to decrease falls.
Members included nurse manager, administrative
director, physical therapy, physicians, Nurse
Practitioners, Nursing staff, Pharmacist, Patient
Care Tech, Nurse Educator, and Performance
Improvement Coordinator. Each member has an
active role to decrease falls and increase fall
risk factor awareness. The committee designed a
Level III Fall Prevention Program adapted from
the John Hopkins tool. The tool identifies
patients at risk for falls and patients at high
risk for injury. Since the formation of the
committee the 6-West fall rate decreased from
12.9 (1st Calendar Quarter 06) per 1000 adjusted
patient days 2.4 (4th Calendar Quarter 06) per
1000 adjusted patient days. For 2007, the BEE
SAFE Committee will focus on implementation and
evaluation of the Fall Risk Assessment tool and
the Risk for Injury (April 2007), implementation
and evaluation of Level III Fall Prevention
Program, integration of the fall risk assessment
tool and history of falls into the Electronic
Medical Record EPIC since the strongest predictor
of future falls is having previously fallen, and
partner with the Loyola Niehoff School of Nursing
to incorporate the BEE SAFE Fall Prevention
Program into the Nursing Student Curriculum.
2
BEE SAFE 6 W Fall Prevention Program
Team Members Dr. Kevin Barton, Barbara Buturusis
Administrative Director, Maria Benetatos, RN.,
Allison Davis, R.N., Tara Dedic, RN., Linda
Flemm, R.N., Donna Fletcher-Gonzales-Pharmacy,
Teresa Fortenberry, R.N., Discharge Planner, Pat
Dominguez, Assistant Manger, Amanda Ewert, RN.,
Judy McHugh, R.N., NQI Project Facilitator, Jody
Nolte, Office Coordinator, Marion Langevin,
R.N., Fall Reduction Liaison, Tonisha Smith, PCT
II., Kate Steinable-Physical Therapy, Joanne
Scharnak, Nurse Educator, Sylvia Williams, R.N.,
Manager/Project Leader, Heather Wojtecki, R.N.,
and Malgorzata Zimowska, R.N. Scribe and Fall
Reduction Liaison.
3
Oncology/Hematology Potential Cause of Falls
BEE SAFE MEETING March 15, 2006
People
Environment
Fall Risks
Clutter Isolation Crowded
Unsteady gait -gait belt Fatigue Weakness Hydra
tion-urination
Lack of Fall Risk Knowledge Patient
Staff
Patient
Documentation
Non-compliant w/activity Language
Barrier Personality
Change of Shift Risk for Fall/Injury
Education -signs -tent cards

Inconsistent Risk Assessment Tool

Patients At Risk For Falls
Clinical Indications
Materials
Other Neuropathy- UE LE Fever/Sepsis Muscle
Atrophy Neuromuscular weakness CNS metastasis Low
blood counts Malnutrition Psych Dizzy r/t low Hgb
Decreased Sensorium
Medications
Lack of assistive devices
No Chair Alarm Pad Alarm baskets Bed Alarm Pad in
OMNI Cell Gait belts
PCA Pump
Sedation Antiemetics- Benadryl, AtivanTM
Pain- Morphine
Confusion Hyponatremia Dehydration
Blue Indicates Program Completed Red Indicates
Programs/Interventions Needs More Planning Green
Indicates Programs in Development Black Indicates
Future Investigation
Confidential For Performance Improvement Purpose
Only
4
(No Transcript)
5
(No Transcript)
6
Solutions Implemented Multidisciplinary Staff
Education New Fall Assessment tool, Tent Card,
Bee Safe Poster New Color-Coded Fall Risk
Flagging System/Magnet Board Appropriate Bed
Alarm Use, One bed alarm per room Safety
Awareness Week Falls and Related Injuries Lunch
and Learn Series Gait Belt Training Bed Alarm
Inservices Fall Documentation Inservice Touch
Therapy Massages for Staff Adapted an
Evidence-Based Fall Prevention Level III
Program Implemented fall level flagging
system Maintain sage environment for all
patients Evaluate medications that may increase
the risk of falling and reassess patients after
giving medications (narcotics, diuretics,
cardiac, and benzodiazepines) Level I low Risk
(Green) All patients initially placed on Level I
unless otherwise indicated Patients and family
are educated on fall preventions (tent cards at
bedside) Level II Moderated Risk ( Orange) Move
patients closer to nursing station and monitor
patients more frequently Implement interventions
for patients with altered mental status (reorient
frequently) Level III High Risk
(Purple) Implement bed/chair alarm on all
patients Implement bathroom buddy/monitor patient
more frequently Appropriate use of gait belt
7
Next Steps Pilot 6 W and BMT Fall Risk
Assessment Tools Pilot Fall Related Injury
Assessment Tool Implement new BEE SAFE
Interventions Integrate fall risk assessment
tools and interventions into the Electronic
Medical Record EPIC Incorporate BEE SAFE Fall
Prevention Program into the Nursing Student
Curriculum Standardized the Adult BEE SAFE Fall
Prevention Program