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:
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:
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.
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.
Kate Ammeraal MSOTR
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
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
Kurt Schuiteman BSN, RN, CEN
April Serene BSN, RN, CEN
Jamie West BSN, RN, CPN
Jennifer Wheaton BSN, RN, RCCN
Lindsey Wiers RN
Nicole Wills MSN, RN, NE-BC, CCRN, CBIS