What is fall prevention?
Fall prevention in healthcare involves managing patients’ underlying risk factors and optimizing their environment to reduce the likelihood of an unplanned descent to the floor. Resources such as Fall Prevention Toolkits have been shown effective in reducing this type of patient safety event.
Table of Contents
- Choosing a Modality: Paper vs Electronic
- Measuring Success and Evaluating ROI
- Implementing The Toolkit and Establishing Buy-In
- Risks and Interventions
- Responsive to Changing Conditions
A hospital is an unfamiliar setting, and every patient is there because of an illness or condition that requires treatment. It’s a recipe that increases the likelihood of falls, one of the most common and most devastating events in any hospital setting.
While the rate of falls varies among hospitalized adult patients depending on the study, multiple studies indicate that 3-4 falls occur per 1,000 bed days.
A fall, especially by a geriatric patient, can be the start of a downward spiral as described by the team that did early research on the use of a fall prevention toolkit. A single fall can have compounding effects and result in fear of falling, reduced mobility, loss of function and greater risk of falls.”
That early research, published in the Journal of the American Medical Association in 2010, found a significantly reduced rate of falls in the hospital setting when a toolkit was added to usual care protocols. Over the next decade and funded through a grant by the Agency for Healthcare Research & Quality, that research team would go on to further refine their toolkit to help facilities prevent falls. And the toolkit resulting from all that work — Fall Tailoring Interventions for Patient Safety (Fall TIPS) — was recently released for free.
In another JAMA study including more than 37,000 patients published in 2020, the Fall TIPS toolkit was tested at Brigham and Women’s Hospital in Boston and 2 other facilities, finding that falls with injury were reduced by 34% while total falls decreased by 15%. Since then, more than 100 hospitals in the U.S. and internationally have used the toolkit.
Choosing a Modality: Paper vs Electronic
When Fall TIPS was first developed, use of the nurse-led, evidence-based toolkit proved to reduce falls by 25% in acute care settings when implemented as part of electronic record-keeping. The Fall TIPS team then set out to create a “low tech” tool that offered the same benefits in preventing falls, the end result being an 11″x17″ laminated poster on which the personalized plan for each patient is marked.
In the EHR version, the patient’s risk factors and tailored interventions automatically populate the Fall TIPS electronic poster, which a nurse then prints and hangs in the patient’s room. While the integration into a facility’s EHR reduces the potential for error, it also requires the involvement of the IT team to set up. The lower-tech, laminated poster version, on the other hand, can easily be filled out with a dry erase marker and updated daily at the bedside. (A full list of the pros and cons of the paper and electronic methods can be found on the Fall TIPS site under the heading “Paper or Electronic?”)
Whether a high- or low-tech solution is implemented, the goal is to use bedside tools to communicate current and changing patient risk factors, so all stakeholders have access to the information needed to engage in prevention activities.
Measuring Success and Evaluating ROI
The human cost of falls is not the only cost. One-third of falls result in injury, and injurious falls can add a week or more to a hospital stay. The same JAMA study from 2020 found that the additional cost was $19,376 to $32,215. And these costs are not reimbursed by the Centers for Medicare & Medicaid Services because most (more than 90%) of falls are preventable.
When implementing a performance improvement tool like Fall TIPS, it’s always a best practice to start by ensuring you can track and measure success for communication to the team on the frontline as well as senior leadership. The best way to accomplish this is through a Patient Safety Event Reporting Application with real-time dashboards. If your tool has a dedicated Falls Dashboard like ADN’s application (see video below), evaluating falls data pre- and post-implementation of a tool like this is much easier.
Implementing The Toolkit and Establishing Buy-In
At the patient level, Fall TIPS is a three-point plan of action:
- Fall Risk Screening/Assessment
- Tailored/Personalized Prevention Planning
- Consistent Execution of Plan
The toolkit is easy enough to use that compliance was above 80% at the hospitals where it was first tested. So with administrative buy-in and training of patient-care staff, Fall TIPS can become a routine and effective part of patient care. (Subsequent research by the Fall TIPS team showed that a compliance rate of at least 80% is necessary to achieve a clinically significant reduction in falls.)
A poster in the patient’s room is the most visible tool in the toolkit (either the laminated version or the EHR printout). But implementation starts at the top with administrative support. That should include engaging any relevant committees and champions. Some organizations may already have a specific fall-prevention task force, or the appropriate body might be a general quality and safety council. Buy-in needs to come from within the existing organizational structure.
Implementation also includes analyzing existing fall-prevention protocols to see how much overlap there is with the best practices. The toolkit includes a tool to assess gaps in protocols, as well as an implementation checklist and training materials for champions and nurses. (To get started implementing Fall TIPS, click here.)
Risks and Interventions
Whether using the high- or low-tech version of Fall TIPS, the result is a personalized assessment of the patient’s risk of falling and a personalized plan to address their specific risk profile.
Does the patient have a history of falls? Are they taking medications that might contribute to unsteadiness? Do they already use a cane or walker? Are they likely to get out of their bed or chair without summoning help?
Once the patient’s risk factors have been committed to the record, interventions to mitigate those risks can also be committed to the care plan. Is a bedpan appropriate, or should the patient be assisted to the toilet? How many helpers does the particular patient need? Is the risk of getting up unassisted so great that a bed alarm is required?
All of the risk factors and interventions should be discussed with the patient and with family members so that everyone involved understands the plan for preventing falls. In fact, whether the patient and/or family can verbalize the patient’s risk factors and the fall-prevention plan are part of the audit questions that internal champions must answer.
Patient and family feedback has affirmed that knowing the plan improves compliance and can help reduce the fear of future falls, a factor in the downward spiral of fall-prone patients.
Responsive to Changing Conditions
Fall TIPS is not a one-size-fits-all plan for every patient, nor is it static for the individual patient. It can be customized as the patient’s condition changes. The patient’s risk factors and appropriate interventions should be re-evaluated daily. The poster features an assessment date so that every care provider can see how current the evaluation is.
A patient may, for instance, be at greater risk of falling and need different levels of assistance immediately after surgery than before. A change in medications may also change risk factors and the interventions needed. With training and consistent use, Fall TIPS can reduce the number of patient falls and reduce the number of injuries associated with falls that do happen.
To download and start using the Fall TIPS Toolkit, click here.
Learn more about how ADN’s Patient Safety Event Reporting Application can help you uncover trends and patterns about falls in your event data.
What is voluntary patient safety event reporting?
Voluntary Patient Safety Event Reporting is a method of collecting details and information about an incident, near miss or unsafe condition in hospitals and other care settings through an electronic or paper-based form submitted by frontline staff.
As research published in 2020 by the Journal of Patient Safety acknowledged, “A natural, human tendency when errors have occurred is to ignore or minimize the error. It takes a lot of work to build an environment that supports the opposite reaction: open and honest reporting of errors so they can be evaluated to contribute to organizational learning.”
It’s counterintuitive but inescapable: To achieve the highest levels of reliability, High Reliability Organizations must defy human nature by eagerly embracing the evidence of failure. This article will suggest six strategies, and even more specific techniques, for creating a culture that encourages — and even incentivizes — team members at all levels to report incidents, near misses and unsafe conditions.
Encouraging and incentivizing reporting requires first understanding the reasons that team members may fail to do so. As the graphic below illustrates:
- Team members must understand the big picture of preventing future patient safety events by analyzing and sharing past errors. Preoccupation with failure is a mindset that must be fostered at every level. Reporting of safety events and concerns must be recognized as a critical component of patient care.
- Team members must be assured that reporting will not create problems — for themselves, their coworkers or the facility. Fear of immediate personal repercussions is a disincentive to future patient safety. If you want to trust your staff to report safety concerns and events, your staff must trust that they will not regret reporting. Snitches prevent stitches!
What strategies and tactics work?
- Regular education and reinforcement
Awareness of patient safety as a science that must be taught and reinforced has been growing, but your hospital or clinic is an amalgam of patient care providers whose immersion in the mindset and culture of patient safety cannot be assumed. Your facility’s safety culture and processes for reporting issues must be central to the onboarding and orientation process.
As writer Susan Trossman described in a 2017 article in The American Nurse, cultural expectations like engaging in daily safety huddles and working collaboratively must be communicated to new hires and then reinforced in continuing training and routine communication. (Her article also describes an added benefit of intensive orientation, at least with nurses: higher rates of employee retention.)
Safety champions — engaged team members with specialized training — are a tried and true method of reinforcing your desired culture of safety, including normalizing routine reporting of events. Appointing champions per department or location is a great way to ensure the focus on reporting gets regularly communicated on the front lines.
- Evidence of effectiveness
Proving to your staff that their reports of errors and near misses don’t disappear into the ether creates a virtuous feedback loop: Reporting results in improvements, which results in more reporting. An analysis of data from more than 200,000 individuals in almost 1,000 hospitals concluded that prioritizing feedback to reporters is one of the most efficient ways to increase the likelihood that a patient safety event will be voluntarily reported. And this was especially true with the most serious patient safety events. (While you are at it, consider using language such as “safety report” rather than “incident report.”)
- Convenient and natural reporting opportunities
You may be familiar with “nudge theory,” the idea that desired behaviors can be fostered by making them more convenient. (This explains the candy bars in the checkout aisles of grocery stores — and Best Buy.) The desired outcome of voluntary reporting of patient safety events can also be nudged by creating convenient, natural reporting opportunities.
One common and effective strategy is the daily huddle, in which patient safety is the central agenda item for all team members. Periodic observation to make sure daily huddles are being used to encourage event and near-miss reporting is a good management technique. Consider adding the daily question: “How is the next patient going to be harmed?”
Anything that requires a lot of time and effort will always take a backseat to the urgency of patient care, so convenient reporting can also be encouraged with user-friendly reporting technology. This free Patient Safety Event Reporting Gap Analysis template can help you conduct a thorough evaluation of how well or poorly your existing tool or process accomplishes the necessary objectives of an event reporting system.
- Management encouragement
Hearing the gospel of voluntary reporting from evangelists at the top of your organization is key to creating and sustaining a culture of patient safety. These messages from leadership are an opportunity to dispel the fear of retribution from reporting events and instead help promote a just culture at your facility. ADN’s Increase Event Reporting Toolkit can help with templates for emails from senior leaders. Hanging posters reminding frontline staffers of the types of events they should report can keep the responsibility for reporting top of mind. (The toolkit also contains a poster template.)
Every communication channel in your organization is an opportunity for reinforcing the message: staff meetings, intranet, newsletters, etc. But it won’t get done unless someone is specifically tasked with adding safety to the to-do list. Staff meeting agendas and newsletters often feature standing items that carry over from one to the next; voluntary reporting should be one of those standing items.
- Recognition and reward programs
Behavior rewarded is behavior repeated. Recognition of voluntary reporting through “good-catch campaigns” can take the form of certificates or plaques and even that most prized reward: a paid day off for the staff member who reports the best good catch each quarter.
If your state has a patient safety recognition program, be sure your good catches are entered. Whether your staff member is ultimately recognized statewide or not, knowing that their focus on safety has not been forgotten reinforces the original recognition.
- Intensive Reporting Days
It may seem counterintuitive in a culture that encourages reporting of incidents and near misses year-around, but designating intensive reporting days results in more reporting. Research published by the Journal of Patient Safety found that it works at all levels of an organization, especially when reporting can be done conveniently and anonymously.
Clinicians, staff members and patients in 10 family medicine clinics were encouraged to make routine reports during a 10-week study, but they were asked to report every error on five specific days. Their anonymous reports could come through a website, paper forms or a voice-activated phone system. During the 70-day study period, more than a third of the reports came on the five days that were designated for intensive reporting.
ADN’s Increase Event Reporting Toolkit includes an Intensive Reporting Day checklist and support materials to help your organization take advantage of this proven technique for improving voluntary reporting.
Then what?
As you implement new strategies and techniques to improve voluntary event reporting, you can track overall improvement and even compare your facility to other hospitals using ADN’s Patient Safety Event Reporting Rate Calculator. The calculator shows how far above or below average your event reporting rate is as well as suggested reporting rate improvement goals and more recommended strategies, tactics and tools based on your facility’s performance.
Event reporting is essential to identifying, understanding, and addressing underlying factors and circumstances that contribute to medical errors. The insight unearthed from reported incidents, near misses and unsafe conditions shed light on fractured systems and processes that might otherwise lay hidden. To help facilities in their pursuit of zero harm, ADN developed an extensive toolkit to help your facility increase event reporting to help you gain maximum visibility into opportunities to improve care outcomes.
What is the High Reliability Organization principle “Preoccupation with Failure”?
Preoccupation with failure in healthcare refers to the need for continuous attention to anomalies that could be symptoms of larger problems in a system. High Reliability Organizations (HROs) that demonstrate a preoccupation with failure strive to detect small, emerging failures because these may be clues to additional failures elsewhere in the system. At its root, preoccupation with failure is a mindset that anticipates and specifies significant mistakes that an organization doesn’t want to make.
Table of Contents
Erin Madden, a patient care assistant at Phoenixville Hospital near Philadelphia, made sure that her patient’s bed wheels were locked before transferring her patient into bed. The bed moved anyway. And while her patient didn’t fall and no harm was done, the incident nagged on Madden’s mind.
At her unit’s daily safety huddle, she reported her concern about unreliable wheel locks. Her report led to the discovery that more than half of the beds on the unit were unstable even when the wheel locks were engaged. That discovery led to assessment and repair of wheel locks hospitalwide — and to Erin Madden being recognized in the Pennsylvania Patient Safety Authority’s annual “I Am Patient Safety” contest in 2017.
This anecdote, in which a relatively low-level care provider recognized the systemic implications of a “near miss” with one patient, illustrates one of the five traits that High Reliability Organizations (HROs) employ in order to operate for extended periods without serious accidents or catastrophic failures: preoccupation with failure.
- The entire staff, from a low-level assistant to the unit-level managers to the hospital administration, recognized the importance of identifying potential safety risks.
- The unit held a daily safety huddle where frontline staffers were encouraged to discuss incidents, observations and concerns.
- The hospital’s management took Madden’s observation seriously and escalated the investigation facility wide as it became clear that the risk was not isolated.
- The patient care assistant’s safety-centered observation — variously known as a “good catch,” “near miss” or “close call” — was recognized by her employer, which nominated her for the statewide award, which has been used in Pennsylvania since 2013 to recognize active commitment to patient safety.
Mindset
Preoccupation with failure is not a checklist, although checklists can certainly be part of patient safety. “Preoccupation with failure is a mindset, a way to mindfully organize work, applied by all staff every day on the job,” researchers at Johns Hopkins Armstrong Institute for Patient Safety & Quality wrote in 2017.
The mindset that is preoccupied with failure “look[s] for errors rather than assuming what is in front of them is correct,” the Armstrong researchers wrote, referring specifically to frontline clinicians. “For example, when nurses conduct a high-risk intravenous medication double check, the second nurse should assume the first nurse made a mistake, hunt for it, and correct it, rather than assume the intravenous pump is working or programmed properly and the medication is right.”
This thought process — something here might harm my patient, and I’m going to find it and fix it — is a preoccupation with failure. But it does not come naturally; it is a habit that must be taught and reinforced. The Armstrong researchers suggested adding preoccupation with failure to classroom training for health care providers — “For example, in a simulation laboratory students or physicians could identify errors with a mediation pump or a ventilator set up.” — and reinforcing the mindset during clinical rotations.
In the health care setting, unit-level managers can continually reinforce the preoccupation with failure during daily huddles or briefings. “Managers can also ask frontline staff that thought-provoking question, how will the next patient be harmed, and use their responses to proactively identify and mitigate those risks,” the Armstrong researchers suggested.
Reporting
Spotting and fixing safety risks before they do harm is not enough. Reporting these near misses or good catches should be seen by frontline caregivers “as equally important in the scheme of event reporting.” Why? Because more near misses reported results in fewer serious events in which patients are actually harmed — the goal of every HRO.
Like preoccupation with failure, reporting good catches must be taught and incentivized. Multiple studies have confirmed that providers report more good catches when they are encouraged to. For instance, the American Academy of Family Physicians National Research Network invited clinicians and staff in 10 family medicine clinics to report errors during a 10-week study. Five days during the study were designated for reporting every error they observed. Ultimately, 37% of the reports were made during the five intensive reporting days.
The same is true internally. The Pennsylvania Patient Safety Authority tracked reporting in four hospitals that had good catch reporting systems in place. Between 2005 and 2016, the number of good catches reported by the hospitals increased by more than 60% (from 33,777 in 2006 to 54,472 in 2016) while the number of serious events decreased by 14%.
Reinforcement
As the example of the defective wheel lock illustrates, the preoccupied mindset and reporting must be followed up with managerial action. That often includes a formalized data collection process — like American Data Network’s Patient Safety Event Reporting Application — but it can also include the virtuous cycle of recognition that incentivizes more alertness and more reporting that reduces harmful events.
Some health care settings have used internal newsletters to recognize good catches, especially those that have led to systemic improvements. Greater Baltimore Medical Center, for instance, used its MD Today publication for physicians to describe the near miss that resulted in epinephrine and ephedrine no longer being stored next to each other in medication storage areas.
One facility that participated in a 47-hospital Good Catch Campaign led by American Data Network Patient Safety Organization (ADNPSO) offered as part of its recognition program an extra vacation day to quarterly award winners.
Next Steps to Become More Preoccupied with Failure
While there’s no single roadmap to becoming preoccupied with failure, a successful focus on failure often starts with obsessive data scrutiny.
The recommended tactics included below all fall into 3 main categories:
- What does my existing data tell me?
- What data am I lacking and how do I get it?
- What effect does the underlying culture of patient safety and reporting have on the quality and quantity of my data?
To become more preoccupied with failure and begin answering these questions, utilize the 7 free tools and resources available below.
What does my existing data tell me?
- Benchmark Your Event Reporting Rate with this Calculator: A strong culture of event reporting is a foundational building block of an overall culture of safety. But assessing the strength or weakness of your culture of reporting can be challenging. ADN’s Patient Safety Event Reporting Rate Calculator shows how your number of events and near misses reported per number of patient days compares to other hospitals’ reporting rates and includes improvement goals and recommended strategies, tactics, and tools based on your rate.
- Catch Failure Hidden in Your Catchall Category of “Other” Event Types: In 2018, ADNPSO conducted a deep-dive analysis of the event type “Other.” Over a four-year period, this catchall category accounted for over 40% of events reported by ADNPSO members. Among the myriad of striking revelations, the death rate of incidents categorized as Other was 3 times higher than ALL remaining event categories combined. Regular analysis of your uncategorized events can provide critical insight into trends and patterns that might otherwise lay hidden.
- Pay Special Attention to Specimens: ADNPSO analyzed 4 years of data and found specimen events consistently ranked among its highest reported errors with 73.7% of the incidents deemed preventable. This led ADNPSO to develop and launch a 9-month Specimen Focused Study aimed at better understanding why these events happen and how to reduce errors across all stages of the Specimen Process (Pre-analytical, Analytical and Post-analytical). Among other successes, participants realized a 147% increase in specimen event reporting during the study and potentially estimated avoidable costs of $420K – $1.04M in just 9 months. Access the free Specimen Error Study Toolkit here.
What data am I lacking and how do I get it?
- Conduct a Gap Analysis on Your Current Event Reporting Process: This easy-to-use, free Gap Analysis Template can help you evaluate your Patient Safety Event Reporting Processes so you can see how well or poorly yours meets the key needs of a high-performing process.
- Get More Proactive with a Good Catch Campaign: A well-run Good Catch or Near Miss Campaign can be an invaluable tool to build trust among quality and safety teams and ultimately a catalyst for decreasing adverse events. Leverage this free Good Catch Campaign Toolkit used in a year-long initiative by 47 hospitals that achieved a 47% improvement in near-miss reporting.
What effect does the underlying culture of patient safety and reporting have on the quality and quantity of my data?
- Assess Your HRO Culture: Utilize this survey toolkit based on a study aimed at creating a tool that helps facilities assess how well or poorly their organization embraces each of the 5 traits of a high reliability organization.
- Conduct Frequent Mini-Patient Safety Culture Surveys: This free Patient Safety “Pulse Check” Survey Toolkit, which includes an automated analytics report, can help your facility gain valuable insight into your progress without having to wait until your next scheduled annual or biennial AHRQ SOPS Survey. Several of the 15 questions in the survey, developed by the Veterans Health Administration (VHA) National Center for Patient Safety, will shed light on how failure is perceived and addressed in your organization.
- Encourage Leadership to Conduct a Culture of Safety Self-Assessment: The American College of Healthcare Executives developed a self-assessment tool for leadership teams to assist organizations in their quest to develop a culture of safety. The survey is organized into six leadership domains: (1) Establish a compelling vision; (2) Build trust, respect, and inclusion; (3) Select, develop, and engage your Board; (4) Prioritize safety in the selection and development of leaders; (5) Lead and reward a just culture; and (6) Establish organizational behavior expectations. ADN packaged this self-assessment in an easy-to-use survey and automated analytics report your organization can use.
For more examples and anecdotes of notable good catches, see the Pennsylvania Patient Safety Authority’s annual “I Am Patient Safety” awards, which include brief descriptions of the award winners:
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/2017IAPS.aspx
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2018_Winners.aspx
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2019_Winners.aspx
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2020_Winners.aspx
For more than 25 years, American Data Network (ADN), which is also the parent company to its Patient Safety Organization (ADNPSO), has worked with large data sets from various sources, aggregating and mining data to identify patterns, trends, and priorities within the clinical, financial, quality and patient safety arenas. ADN developed the Quality Assurance Communication (QAC) application, with which hospitals, clinics, rehabs, and other providers record and manage patient safety events. By entering events into ADN’s QAC application and submitting them to ADNPSO, information is federally protected and thereby privileged and confidential. These protections provide a safe harbor to learn from mistakes and improve patient safety.
The Safety Organizing Scale (SOS) was designed to analyze self-reporting team behaviors that contribute to an organization’s culture of safety.
ADN’s Patient Safety Event Reporting Rate Calculator can help your team assess how your number of events reported per number of patient days compares to other hospitals’ reporting rates.
This free Gap Analysis template can help you conduct a thorough evaluation of how well or poorly your existing tool or process accomplishes the necessary objectives of an event reporting system.