At the end of 2023 and into 2024, Kaiser Permanente Santa Rosa experienced a notable increase in patient fall rates, including falls with injury, despite the continuation of the 2022 performance improvement strategies. Recognizing the need for new approaches, the Falls Workgroup initiated several performance improvement plans using the A3 template for process improvement and Plan-Do-Study-Act (PDSA) cycles.
Key interventions included:
- Falls Bundle Implementation: The workgroup focused on adherence to the falls prevention bundle, utilizing the Schmid Fall Risk Assessment Tool. Particular attention was given to the Schmid mentation score to ensure that all qualifying patients had the bundle in place.
- Components of the Bundle: Yellow gown, socks, band, blanket, bed/chair alarm activation, and patient education on fall risks.
- Visual Cues: The yellow components provided a clear, immediate visual indicator for the care team and patients, enhancing awareness of fall risk.
- Quality Audits: Regular audits were conducted to monitor adherence to the bundle and identify areas where implementation drift occurred.
These measures resulted in a reduction in fall rates; however, sustained success and the overall target had not yet been achieved.
The Falls Workgroup collaborated with the Comprehensive Unit-based Safety Program (CUSP) teams from the ICU and Medical-Surgical units, leveraging their successful approaches from mobility and tooth-brushing performance improvement work as a model for progress.
“Falling Star” Safety Initiative:
- A staff-led safety initiative introduced the Falling Star signage system, which included:
- Clear Visual Cues: Signs outside patient rooms identified those at risk for falls, increasing team awareness.
- Checklist Integration: Each sign featured a shift-specific checklist to ensure adherence to the falls prevention bundle, including all necessary interventions such as yellow gown, socks, band, blanket, bed/chair alarms, and patient education.
- Impact: This initiative increased awareness and improved consistency in implementing bundle elements.
Despite these improvements, fall rates remained higher than desired, prompting further review and analysis by the Falls Workgroup.
- Identifying the Gap: The team recognized that simply knowing a patient is at risk for falls was insufficient.
- New “Safety Stop” Sign:
The Falling Star signage was retired and replaced with a redesigned Falls Safety Stop sign, which includes:
- Individualized Risk Factors: Each sign highlights specific risk factors unique to the patient.
- Tailored Prevention Measures: Prevention strategies are linked directly to the identified risk factors, providing a more personalized and effective approach to fall prevention.
The Falls Workgroup remains dedicated to evaluating the effectiveness of these strategies, using data to refine processes and achieve sustained success in fall reduction. By fostering collaboration and continually innovating, the team aims to create a safer environment for all patients. This ongoing effort underscores the commitment of the KP SRO team to refine and reinforce falls prevention strategies, ensuring patient safety remains a top priority.