EP17EO

 

Culture of Safety EP17EO

 

Using the required empirical outcomes (EO) presentation format, provide one example of an improved patient safety outcome associated with clinical nurse involvement in the evaluation of patient safety data at the unit level.

 

 

Example: Clinical Nurses Assist in Decreasing Total Patient Fall Rate on 1 East

Problem

Increased total patient fall rate on Catholic Health Initiatives (CHI) St. Vincent Hot Springs (SVHS) 1E Geripsych (1E).

 

Pre-Intervention

At CHI SVHS 1E, the goal is avoidable patient harm, including harm associated with patient falls. 1E had an overall increase in the rate of total patient falls per 100 patient days from December 22 to December 28, 2023, which was 17.39. This rate was calculated by taking the number of total patient falls, divided by the total patients for the week on 1E, multiplied by 100.

 

Knowing the 1E total patient fall rate increased significantly in one week, the 1E Unit-Based Council (UBC) met on December 28, 2023, to discuss what to do. The UBC as a team, led by Kimberly Greathouse, RN, Clinical Nurse, evaluated the total patient falls safety data for 1E from the week.

 

This evaluation of patient safety data showed common causes of falls, including lack of fall precautions, impulsiveness related to toileting, decreased supervision in rooms, and opportunities for team members to be present in the dayroom. The dayroom is a common area on the unit.

 

The UBC voted to immediately develop a falls task force to create an action plan (rapid cycle improvement) to decrease the total patient falls rate on 1E. Janna Murphy, RN, Clinical Nurse, led the falls task force and the group developed a plan that day.

 

Goal Statement

Decrease the total patient falls rate for CHI SVHS 1E.

 

Participants

 

1 East Falls Task Force
Name/Credentials	Discipline	Title/Role	Department
Kimberly Greathouse, RN	Nursing	Clinical Nurse, Patient Care Coordinator, UBC Chair	1E Geripsych
Janna Murphy, RN	Nursing	Clinical Nurse, UBC Co-Chair	1E Geripsych
Teresa Brooks, RN	Nursing	Clinical Nurse	1E Geripsych
Angie Byrd	Therapy	Recreation Therapist	1E Geripsych
Madeline Larkin, LMSW	Social Worker	Social Worker	1E Geripsych
Lauren Brewer, PCT	Nursing	Patient Care Tech	1E Geripsych
Hallie Weatherford, PCT	Nursing	Patient Care Tech	1E Geripsych
Kaylin Sorrell, RN	Nursing	Clinical Nurse	1E Geripsych
Carolyn Strange, RN	Nursing	Clinical Nurse, Patient Care Coordinator	1E Geripsych
Jacob Martin, PCT	Nursing	Patient Care Tech	1E Geripsych
Melinda Castenada, UC	Nursing	Unit Clerk	1E Geripsych
Jazmine Talbert, PCT	Nursing	Patient Care Tech	1E Geripsych
Lynda Lynch, BSN, RN	Nursing	Clinical Nurse, Patient Care Coordinator	1E Geripsych
Anglia Tullos, RN	Nursing	Patient Care Tech	1E Geripsych
Molly Brennan, RN	Nursing	Clinical Nurse	1E Geripsych
June Marie Thompson	Nursing	Patient Care Tech	1E Geripsych
Cynthia Rico	Nursing	Patient Care Tech	1E Geripsych
Chantel Williams	Nursing	Patient Care Tech	1E Geripsych
Ashton Mehalic	Nursing	Patient Care Tech	1E Geripsych

 

Description of the Intervention December 29, 2023, to January 4, 2024
The 1E falls task force action plan included:

• Ensuring all fall precautions were in place per the policy and all patients were classified as a high fall risk. Most of the patients are at a high fall risk, due to mental status and psychotropic medications. The 1E team found that they were not ensuring all patients had fall precautions related to their fall risk score. Fall precautions include yellow socks, fall alarm or chair alarm, use of gait belts, orienting patients, bed in lowest position, call light within reach, and patient education. Also, the patients wear street clothes, so an appropriate intervention is to make sure the patient’s clothes fit properly (rolling pants up to prevent tripping, removing shoes for improper fit, etc.). The use of the checklist, completed by a charge nurse at least once a shift, is to address missing fall precautions by immediately correcting when found
• Use of gait belts. Any patient that is ambulating must have a gait belt in place. The 1E team found that gait belts were not being used during their evaluation of the unit safety data.
• All coworkers remained in the dayroom during the day. This allowed the patients to be in the dayroom to interact with the other patients and allowed the coworkers to all be in one specific location to always monitor patients. In the event a patient needed to return to the patient's room, the patient would be escorted back to the room by a staff member.
• All patients must have a bed alarm set to auto-alarm and position to setting 2 to allow each bed alarm to sound if the patient attempted to get out of bed. The team discussed a knowledge gap associated with bed alarms during their evaluation of falls data. Not everyone was aware that there were fall alarms on beds or how to set them.
• Proactive toileting every two hours to prevent the patients from being impulsive when needing to go to the restroom. The team identified this as an opportunity during their evaluation of the falls data.

 

The action plan was discussed at shift safety huddles every day and every shift for one week to ensure the team was aware of the opportunities to prevent falls. All interventions were fully implemented by January 4, 2024.

 

Clinical nurses in the 1E Falls Task Force, led by Murphy, were involved in the evaluation of falls patient safety data at CHI SVHS 1E. The evaluation of data resulted in an improvement in total patient falls. The rapid improvement action plan impacted the outcome by ensuring fall precautions were in place and everyone had an identified role to prevent falls.

 

References

Commission, C. E. (n.d.). Post Fall Assessment and Management Guide . CEC. https://www.cec.health.nsw.gov.au/keep-patients-safe/older-persons-patient-safet y-program/fall-prevention/hospitals/post-fall

 

Gray-Miceli, D., & Quigly, P. (2012). Fall Prevention: Assessment, Diagnoses, and Intervention Strategies. In: M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker (Eds.), Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Ed., pp. 268-97.

 

Outcome

(Evidence EP17EO-1, 1 East Falls Rate Graph)