{"id":2249,"date":"2025-02-21T13:23:28","date_gmt":"2025-02-21T21:23:28","guid":{"rendered":"https:\/\/nursingncal.kaiserpermanente.org\/annual-report\/?p=2249"},"modified":"2025-02-26T18:11:23","modified_gmt":"2025-02-27T02:11:23","slug":"reduction-of-falls-with-injury","status":"publish","type":"post","link":"https:\/\/nursingncal.kaiserpermanente.org\/annual-report\/empirical-quality-outcomes\/reduction-of-falls-with-injury\/","title":{"rendered":"Team works to reduce falls with Injury\u00a0"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row][vc_column][vc_column_text]<span data-contrast=\"auto\">Falls with Injury observed\/expected ratio peaked in October 2023 at 1.92. The falls committee, made up of interdisciplinary team members, participated in a gap analysis to identify gaps in adherence to the fall prevention bundle.\u00a0 <\/span><\/p>\n<p><span data-contrast=\"auto\">PDSA cycles were then developed based on what was identified in the gap analysis. Key focus areas were standard work for fall risk\/history of falls reviewed on all new admissions and reported out at the daily safety huddle. <\/span><\/p>\n<p><span data-contrast=\"auto\">Chair alarms were mounted in all patient rooms, fall prevention supplies standardized across units with an increase in par levels.\u00a0 <\/span><\/p>\n<p><span data-contrast=\"auto\">Findings from the root cause analysis from all falls with injury events were shared with the clinical nurses via SBAR format.\u00a0 Education was provided on the correct bed alarm use and the importance of call light responsiveness.\u00a0<\/span><span data-contrast=\"auto\"> Collaboration between inpatient nursing, emergency department, rehab services, and quality to improve handoff communication between teams.\u00a0 <\/span><\/p>\n<p><span data-contrast=\"auto\">The clinical nurse champions rounded on patients and environment, conducting patient interviews and education, identified any opportunities, created solutions, provided peer to peer feedback and knowledge sharing.\u00a0 To raise awareness and visibility of progress of the falls work, rubber duckies were added to the jar in the breakroom each day the unit went without a fall with injury.\u00a0 This improvement project has assisted with transforming culture, increasing teamwork, ownership of practice by the clinical nurses on each unit, empowerment of clinical nurses to get involved and create change, and increased staff retention.\u00a0 <\/span><\/p>\n<p><span data-contrast=\"auto\">The incredible falls work has been sustained and current data through September 2024 has the falls with injury observed\/expected rate at 0.94.\u00a0 The 5<\/span><span data-contrast=\"auto\">th<\/span><span data-contrast=\"auto\"> floor team has just celebrated 365 without a fall with injury on their unit.\u00a0\u00a0<\/span><span data-ccp-props=\"{}\">\u00a0<\/span><\/p>\n<p><span class=\"TextRun SCXW165407395 BCX0\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW165407395 BCX0\">The work was led by: Patricia Mittone MBA, BSN; Wei-Chien Chang, BSN, RN; Sara Stein, BSN, RN; <\/span><span class=\"NormalTextRun SpellingErrorV2Themed SCXW165407395 BCX0\">Chavoy<\/span><span class=\"NormalTextRun SCXW165407395 BCX0\"> Kellogg, BSN, RN; Key Harper, BSN, RN; Linda Ortiz, PT; Virginia <\/span><span class=\"NormalTextRun SpellingErrorV2Themed SCXW165407395 BCX0\">Breslo<\/span><span class=\"NormalTextRun SCXW165407395 BCX0\">, RN; Shirley Hasson, BSN, RN; Ashley Thompson-Brundidge, MSN, RN; Cyntia Boter MSN, RN; and Alex Quiroga.<\/span><\/span><span class=\"EOP SCXW165407395 BCX0\" data-ccp-props=\"{}\">\u00a0<\/span>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_single_image image=&#8221;2177&#8243; css=&#8221;&#8221;][\/vc_column][\/vc_row]\n<\/div>","protected":false},"excerpt":{"rendered":"<p>Falls with Injury observed\/expected ratio peaked in October 2023 at 1.92. The falls committee, made up of interdisciplinary team members, participated in a gap analysis to identify gaps in adherence to the fall prevention bundle.\u00a0<\/p>\n","protected":false},"author":2,"featured_media":2710,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_custom_body_class":"","_custom_post_class":"","footnotes":"","_links_to":"","_links_to_target":""},"categories":[1],"tags":[],"ncal_area":[95],"site_only":[],"report_year":[58],"class_list":["post-2249","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-empirical-quality-outcomes","ncal_area-san-rafael","report_year-58","entry","has-media"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v26.8 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Team works to reduce falls with Injury\u00a0 - Kaiser Permanente Northern California 2024 Annual Nursing Report<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/nursingncal.kaiserpermanente.org\/annual-report\/empirical-quality-outcomes\/reduction-of-falls-with-injury\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Team works to reduce falls with Injury\u00a0 - Kaiser Permanente Northern California 2024 Annual Nursing Report\" \/>\n<meta property=\"og:description\" content=\"Falls with Injury observed\/expected ratio peaked in October 2023 at 1.92. 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