Kaweah Delta Health Care District in Central California, underwent a falls prevention program redesign in 2013. The work of Patricia Quigley, PhD, RN, served as the framework for the redesign. Outcomes data were analyzed in an effort to identify unit-level and organizational opportunities for improvement. While many opportunities were identified in this discovery process, four opportunities rose to the top of the list.
Opportunities for improvement were identified as starting points to sustaining success in falls prevention:
- Knowledge deficits
- Attended toileting
- Standardized post-fall assessments
- Systemic root cause identification paired with unit-level accountability for falls established through Falls University
Falls prevention education was provided to clinical nursing teams and expanded to include all new employees upon hire to increase awareness that falls prevention is an organizational responsibility. Attended toileting was introduced as a required intervention for those at-risk as it was identified that many of our falls occurred as a result of unattended toileting. A post-fall care and management process was developed and introduced, which included debriefs and escalated nursing assessments. Lastly, Falls University was established to review and discuss each fall on a weekly basis with the goal of identifying, addressing, and disseminating root causes.
Of all the listed interventions, Falls University was the strategy that helped Kaweah Delta Health Care District begin to improve and sustain reductions in total falls, total injury falls, and falls with severe injuries. Since 2013, Falls University is held each week to review the previous week’s falls with staff members involved in the event, as well as the nursing leadership of the unit in attendance. A standardized root cause analysis tool is used to guide the review, discussion, and evaluation of the event among attendees. Falls University takeaways (root causes, improvement strategies, processes, and practice recommendations) are disseminated to clinical staff members and leaders weekly to share lessons learned broadly in the organization. Falls University has encouraged accountability for improving outcomes through discussions at staff member and unit-level safety team meetings to address falls prevention at the unit level.
For more information, please contact Rose Newsom, MSN, NE-BC, Director of Nursing Practice, Kaweah Delta Health Care District, at firstname.lastname@example.org.