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Published on November 18, 2021

Creating a Culture of Patient Safety - Fall PreventionCreating a Culture of Patient Safety

“One fall is too many,” says Jane Johnson, Executive Director of Critical Care and Perioperative Services at Cape Cod Healthcare. “That is somebody’s mother, sister, brother or grandfather who could now be potentially injured. We are all part of this community. Our goal is zero patient harm.”

Four months ago, Johnson was tasked with finding a successful fall prevention and patient safety program to implement at Cape Cod Hospital and Falmouth Hospital. As she looked at different areas and departments at both locations, she discovered there was no overall cohesive plan.

“I interviewed people from all areas—facilities, maintenance, EVS, kitchen, registration, front desk, EC, you name it,” says Johnson. “People either didn’t know how to identify that a patient was a fall risk or they weren’t current on what we were using as a fall risk identifier. Responses were all over the board. I knew that we didn’t have a standardized approach.”

After thorough research, Johnson found a simple yet successful plan developed at Brigham and Women’s Hospital about 10 years ago called the Fall TIPS Safety Program (Tailoring Interventions for Patient Safety)—an evidence-based fall prevention tool kit that consists of a risk assessment and customized care for each patient. The plan helped decrease falls and patient injuries, says Johnson, adding 150 hospitals have adopted it as well. The keys to its success are standardized language, universal precautions and consistent communication among caregivers, patients and their families.

Universal language: Brightly colored posters

On Nov. 9, Cape Cod Healthcare will roll out this new patient-safety initiative at Cape Cod Hospital and Falmouth Hospital, designed to help keep patients safe and to improve the channels of communication. The main part of the plan includes displaying new fall risk signs (similar to a construction site sign) and brightly colored posters listing a patient’s fall risks and interventions in every room of in-patient care—places where patients are expected to stay for long periods of time.

There are a variety of reasons a patient may fall: Some may forget they are hooked up to an IV or are on medication that might make them dizzy. Even families who think they are helping bring a family member to the bathroom, for instance, don’t realize he or she is at risk for falling.

“The poster is meant to be a communication tool among caregivers, nurses, nurses’ aides, but also, more importantly, between families and patients,” says Johnson. The laminated poster, which slides in and out of a plexiglass frame, features a space for the patient’s name, date, a check list for fall risks (including unsteady walk or history of falls) and fall interventions (such as walking aides or if they need one or two people for assistance out of bed).

“Everyone can see this, including friends and family,” says Johnson. “If someone comes into help, they know right away what the patient’s level of ability is.” For each patient, the nurse will fill out the poster and review the fall Morse Fall Scale Risk Assessment (a change from the Hester Davis Fall Risk Assessment), which details a patient’s history of falling, gait and mental status. “Ideally, this would be completed with the patient because it’s been proven that patients who have been involved in their plan of care and understand why they have interventions, are much less likely to fall,” says Johnson.

In addition, at-risk patients will now wear orange socks and wristbands (a change from yellow to orange).

One of Johnson’s goals is to empower non-clinical people in the hospitals to answer a patient’s call bell because it might be that one minute that makes all the difference. ‘They could say, “Hold on while I get someone or they look at the board and say, “This person needs two people. Let me get someone else to help.”

Patient safety ‘champions’

Johnson says she will rely on unit-based “champions”—nurses, nurses’ aides, EVS, PT and clinical leaders—to help educate the staff and assist with PI. They will check to see if the board is up to date and speak to the patients and families to make sure they understand the board. “The poster isn’t meant to add an extra step to your fall assessment, it’s meant to complement it and explain the importance of it,” says Johnson. The falls committee has representatives from In-Patient Nursing, Urgent Care, Behavioral Health, EVS, Facilities, Kitchen, Biomed, Security, EC, Pedi/OB, Education, Pharmacy, IT, Lab and PT/OT.

Everyone who works here, says Johnson, touches a patient, so all staff has been trained to identify a patient who is at risk and understand the goal. “I want non-clinical people to know what we are putting in place and feel empowered to answer a call bell,” says Johnson. “This is a whole organization endeavor to create a cohesive team approach to patient safety.”

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