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Abstract
Background Patient falls can lead to negative outcomes including increased length of stay, decreased patient satisfaction, and reduced quality of life.
Objectives The objective was to decrease inpatient falls and falls with injury by 30%. Within 6months.
Methods Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) methodology was used as a framework to reduce falls. A root cause analysis identified active and latent factors. Addressing a multifactorial problem required improvement efforts to be implemented at each step. A standardized visual guide for universal, low, medium and high-risk fall interventions was created. This tool allows clinical care teams to reliably communicate and apply interventions based on fall risk score. This checklist is in the patient’s rooms with patient centered fall risk score and interventions allowing care providers each shift to confirm. As a part of the process improvement effort, the fall supply closet was redesigned to standardize, fall supplies and use visual management to identify fall safety items. As the team evaluated contributing factors, equipment was a latent factor. Bed/chair alarm cords were frequently plugged into incorrect connection sites leading to alarm failure. Color-coding alarm cords removed the risk of error. Sustainability of improvements included ongoing education through scheduled competencies, leadership rounding, data analysis for patterns/trends.
Results Total inpatients falls/1,000 patient days was reduced from 5.0 to 3.0 (ttest, p<0.001 figure 1). Inpatient falls with injury/1,000 days was reduced from 0.58 to 0.16 (Mann-Whitney, p = 0.02 figure 2). AHRQ estimated an additional cost for hospital-acquired falls to be $6,694. Average decrease of 6 falls/month, annualized cost savings estimated at $481,968.
Conclusions Lessons learned included: essential role of leadership involvement in systemic process improvements to patient safety, complex initiatives require process level intervention and cultural change, sustainable PI requires a diverse team. The improvement work around fall reduction spearheaded a system-wide initiative related to safety-first.