Setting the Standard: Reducing Falls with Injury
Sheila Gordon, RN, MS                                                  
Director, Clinical Effectiveness - Fort Sanders Regional Medical Center

To reduce the rate of patient falls with severe injury to below 0.25 per 1000 patient days. To reduce patient harm from falls with severe injury by 25% in calendar year 2010 from 10 to 8 events and by 20% in calendar year 2011 from 6 to 5 events. FSRMC has had a falls prevention process in place for several years, however we wanted to take our program to the next level; preventing injuries from a fall. Our target population was patients who were identified as a falls risk level II, who had certain conditions that put them at a higher risk for being injured. The Interdisciplinary Falls Reduction team was challenged to implement change through a rapid cycle improvement process. A Falls Risk for Injury Protective Bundle Assessment and Intervention Tool was developed. Certain interventions for every falls risk level II patient like scheduled toileting, bed alarm, gait belt, and then others to consider like low bed with mats. The fall events and compliance to the bundle is monitored by senior leadership weekly through a patient safety scorecard.


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