Patient Safety

Blackrock Clinic Patients Patient Safety

At Blackrock Clinic Keeping Our Patients Safe Is The Right Thing To Do!

Falls Awareness

Our aim is to reduce patient falls, in particular those that result in patient injury, through a falls prevention programme.

Falls prevention is becoming a very pressing risk management challenge for hospitals. Studies by “Olivet et al (2010)” state that the majority of hospital beds in developed nations are occupied by older people. With populations aging, projected increases in the number of people surviving with functional and cognitive impairment and multiple long-term conditions, these trends are likely to continue.

In Ireland, older person admissions are considered a significant financial burden. A cost of about €10.8 million per year has been attributed to patients admitted to one Irish University teaching hospital (Cotter et al. 2012). This study also stated that there is a lack of cohesive falls prevention strategies at a national level.

Studies by “Kolin et al. (2010)” showed that on average:

  • 30% of all falls reported result in some form of injury.
  • Around 80% to 90% of falls in acute hospitals are un-witnessed.
  • 50% to 70% occur from the bed and bedside chair.
  • 10% to 20% of falls occur in toilets or bathrooms (Oliver et al, 2010).

All patients attending Blackrock Clinic are assessed and reassessed for a falls risk. This risk assessment provides a numeric value to the risk of that patient falling. In 2012 the Board of Blackrock Clinic set a benchmark of 0.30% fall rate for inpatients. This equates to 3 falls per 1000 bed nights.

Validation

When an inpatient sustains a fall, a Blackrock Clinic “Falls Reporting Form” is completed. The patient is assessed by the Hospital staff, who complete the “injury and cause” section of the form.

All forms are then sent to the Quality Department for input onto their system and analysis. The Quality Department validates by:

  • Cross reference to the medical record.
  • Cross reference to the patient information system.
  • Cross reference directly with the nursing staff.

The tables below demonstrate the reported number of inpatient falls, Jan 13 – Jun 14:

HOSPITAL INCIDENTS

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Number of falls resulting in no injury

0

10

8

9

4

9

1

1

18

2

3

12

0

13

13

3

15

7

Bed nights

3854

3567

3359

3451

3169

3510

3374

3020

3554

3622

3784

3325

3,764

3,753

3,970

3,728

3,748

3,373

Rate of no injury per 1000 bed nights

0.00

2.80

2.38

2.61

1.26

2.56

0.30

0.33

5.06

0.55

0.79

3.61

0.00

3.46

3.27

0.80

4.00

2.08

Mean per year

1.85

1.85

1.85

1.85

1.85

1.85

1.85

1.85

1.85

1.85

1.85

1.85

2.28

2.28

2.28

2.28

2.28

2.28

Rolling mean

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

Table 1: Shows the reported number of inpatient falls resulting in no injury for Jan 13 – June 14.

HOSPITAL INCIDENTS

Jan-13

Feb-13

Mar-13

Apr-13

May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Number of falls resulting in injury

1

5

1

4

2

9

0

11

5

2

3

8

0

3

10

2

7

4

Bed nights

3854

3567

3359

3451

3169

3510

3374

3020

3554

3622

3784

3325

3764

3753

3970

3728

3748

3373

Rate of injury per 1000 bed nights

0.26

1.40

0.30

1.16

0.63

2.56

0.00

3.64

1.41

0.55

0.79

2.41

0

0.80

2.52

0.54

1.87

1.19

Mean per year

1.23

1.23

1.23

1.23

1.23

1.23

1.23

1.23

1.23

1.23

1.23

1.23

1.16

1.16

1.16

1.16

1.16

1.16

Rolling Mean

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

1.22

Table 2: Shows the reported number of inpatient falls resulting in injury for Jan 13 – June 14.

After in-depth analysis of this data, Blackrock Clinic implemented an Action Plan:

  • A falls group was set up in June 2014
  • Feedback on the breakdown of the falls was provided to the Heads of all Departments.
  • A ‘call don’t fall’ campaign was launched
  • A “Culture of Safety” video plays at intervals in the patient reception area
  • A “Culture of Safety” video plays on the education channel in all patient rooms
  • A “Culture of safety” video link can be found on the Blackrock Clinic Website
  • A Multidisciplinary approach was implemented to address the number of falls associated with toileting/bathroom activities; reaching for items:
  •  All staff who enter a patients room are to ask whether the patient needs to use the bathroom.
  • All staff who enter a patients room are to make sure that all patient belongings are within easy reach.
  • The Universal Falls Protocol was re -launched.

A target to reduce falls has been set for the second half of 2014.