It is estimated that annually somewhere between 700,000 and 1,000,000 people fall in the hospital. Falls can lead to additional injuries like internal bleeding, fractures or prolonged hospitalization, which is why Alameda Health System (AHS) made serious changes to reduce falls.

“We pulled together a steering committee early January to figure out what we could do to decrease falls systemwide. Quality Analytics provided extensive data on falls and we were able to narrow it down by number of falls, time of day, day of the week and reasons why.” said Olivia Kriebl, AHS magnet program director. “There were many factors at play, some patients were trying to get to the bathroom, some patients were dizzy from medication, so the Steering Committee came up with best practices for our patient care providers on fall prevention.”

A fall risk assessment was mandated for each patient who was hospitalized. Staff are required to ask patients questions like, have you ever fallen before? Do you have trouble walking? If patients are deemed a high fall risk they received special “color-coding” to visually help staff, a yellow star was placed outside their room by their name and the patient received yellow non-skid socks to wear and yellow blankets in their room. This way staff can easily tell if someone was a fall-risk.

Next, nursing staff were reviewed on the process of “Purposeful Hourly Rounding” with the staff asking specific questions each hour while in with a patient. Do you have to go to the bathroom? Are your personal belongings nearby so you do not have to get up to reach them? Are you in any pain? Do you need to be repositioned? By asking these questions frequently patient’s needs were addressed and fewer patients would try to get out of bed and potentially fall. Patients feeling pain were more likely to take medication that might make them dizzy. Pharmacists were included in the overall fall prevention plan and provided a list of medications, or combinations thereof that are more likely to make patients dizzy or disoriented.

“While the nurses and Nurse Leaders were making rounds, the Quality Managers also made rounds. They checked for things like proper safety equipment, use of the yellow visual cues, bed location in each room and staff knowledge of the fall risk patients,” said Kriebl. “We increased our patient education, creating brochures and posters that teach patients about preventing falls in their stay. And lastly, we did our best to ensure that all staff, providers and patients were aware of our Fall Prevention Clinic.”

The success of the work is due to the great partnership of all disciplines to decrease patient harm. Nurses, physicians, pharmacists, Bio-med, Materials Management, Clinical Education and all areas of Quality came together to support safer patient care.