In January 2016, the Spectrum Health Grand Rapids (SHGR) falls committee identified the need to restructure. This was based on the need for quality improvement related to falls and expanding scope of care areas. In response to this identified need, a Falls Steering committee was created in April 2016 along with three subcommittees:

  1. Inpatient/Emergency Department (with adult and pediatric workgroups)
  2. Outpatient/Procedural/Diagnostic
  3. Spectrum Health Continuing Care (SHCC)

The subcommittee format accommodates variation in practice and allows the teams to focus on scope and interventions based on a specific population. The identified goal is to improve the structure needed to reduce falls and falls with injury across SHGR. The outcome measure is Falls with Injury rate.

Investigating the root cause of patient falls was identified as key to fall reduction. The SHGR falls committee worked with the community hospitals, SHCC, and Organizational Risk Management to revise the current Event Reporting System (ERS) form to collect meaningful data on the root cause of the fall. The changes were implemented June 2016. The committee is now equipped to derive the root cause of falls and the most prevalent fall risk factors of our patients who sustain a fall in order to better inform our prevention strategies.

Additional interventions included:

  • Implemented a post-fall huddle intervention (Plan Yellow) (April 2015 – current)
    • 2 units (IRC and 2S) piloted a post fall huddle including patient, family, and interdisciplinary care team
    • Learnings from the fall shared with entire team was the most valuable piece of this intervention
    • All units encouraged to share fall learnings with team and template distributed
  • Developed and disseminated provider awareness/education for the fall prevention program (June-September 2016)
    • Providers made aware of fall prevention program, goals, and processes
    • Providers asked to partner with nursing in the patients plan of care as it relates to fall
    • Providers discouraged from discontinuing fall prevention interventions
  • Developed and implemented guidelines on patient refusal of fall risk interventions (June – December 2016)
    • Guidelines created with Risk and Patient Relations outlining process for addressing both competent and incompetent patients refusing fall risk interventions
    • Focus on assessing root cause of refusal, patient education, documentation, and individualization of the plan of care
  • RN/NT/rehab education on use of the iBed/secure environment check for fall prevention (October – November 2016)
    • Education on performing a safe environment check and the importance of a safe environment in preventing patient falls
    • Set expectation around use of iBeds for fall prevention, education on how to use, and case studies on how to select the appropriate bed zone bases on patient fall risk factors.

Current work of the falls committee is in transforming the fall prevention program in preparation for the Nexus transition. In August 2016, the committee selected new fall risk assessment tools for the various care areas described above. The committee continues to work on future state processes and how the fall prevention program will change with the implementation of the new risk assessment tools.


Inpatient Falls with Injury

In the pre-intervention period (October 15 – January 16) there were 47 Inpatient Falls with Injury per 1000 patient days. In the post intervention period (July 16 – October 16) there were 34 Inpatient Falls with Injury per 1000 patient days, signaling a 28% reduction in the Inpatient Falls with Injury Rate.

Falls Committee Members:

Kate Ammeraal MSOTR
Christina Antcliff
Sylvia Baird DNP, MM, BSN
Tawan Bausano RN
Kate Bredeweg (Ortho) MSN, RN, AGCNS-BC, ONC
Sue Brooks MSN, RN, ACCNS-AG
Stephen Essenburg MSN, RN
Michelle Hearn PharmD
Laurel Jander BSN, RN, NE-BC, CBS
Alisha Kittlaus
Sandy Knight BSN, RN, BMTCH, OCN, NE-BC
Renee Krueger BSN, RN, CBIS, CRRN
Glenna Mindling BSN, RN, ONC
Kevin O’Brien BSN, RN
Don Packard RSMS Admin. Rehab Operations X
Kendra Peot BSN, RN, ONC
Therese Reilly
Kirk Rykse
Kurt Schuiteman BSN, RN, CEN
April Serene BSN, RN, CEN
Mike Sonuga
Sue Teman
Alexandria Weber
Jamie West BSN, RN, CPN
Jennifer Wheaton BSN, RN, RCCN
Lindsey Wiers RN
Nicole Wills MSN, RN, NE-BC, CCRN, CBIS