Published by: Janet Kosewic on 3/6/2013 12:51:58 PM
In recognition of Patient Safety Awareness Week (March 3-9), the NAPH Safety Network will feature posts from staff at member hospitals. The NAPH Safety Network is a Partnership for Patients hospital engagement network that aims to reduce nine preventable hospital-acquired conditions by 40 percent and 30-day readmissions by 20 percent by 2013.
San Francisco General Hospital and Trauma Center has joined the NAPH Safety Network (NSN) to reduce patient falls with injuries by 40 percent by the end of December 2013. This ambitious goal has been wholeheartedly embraced by patient safety, quality and executive leaders. Yet we found when conducting our unit “reality rounds” that staff did not seem to be feeling the same sense of pressure to meet the goal.
Reality rounds are rounds we do to see what is really happening on the units. Unlike regulatory rounds, on reality rounds there is no right or wrong answer. For instance, when we did falls reality rounds, we thought that the nursing staff were using the plan of care to communicate falls risk. In fact, they were not, because they don’t find it to be a valuable tool.
So we made a change. “Driver diagrams” are used by improvement teams for analysis, organization and communication of information to help direct improvement work. The NSN provided us with a completed driver diagram tool to help us reduce falls. We added fall communication to our driver diagram when we discovered that staff often were not aware that a patient they were caring for had fallen during hospitalization. Several different measures were tested and trialed to improve this important information.
The “fall story” is one tool to help improve communication with all staff about a patient who has fallen.
These fall stories originally started out as a 5-minute summary of a recent fall at the beginning of our interdisciplinary fall team meetings. They included what staff learned from each fall and the key interventions identified. The stories helped the team learn that falls occur in all areas and that there are many similar obstacles to preventing them.
Sharing stories of falls brought the team together and strengthened our resolve to improve, especially when the story underlined a gap in our current fall reduction process. Now, instead of verbally sharing fall stories, they are printed on the back of the meeting agenda. They can then be brought back to each of the departments and posted on the fall dashboard data wall where staff can read them and the unit fall team representative can review them at their unit safety huddle. We have seen that individual units are communicating more about patient falls, and staff are energized and motivated by the fall stories.
Janet Kosewic, MSN, RN, CNL
Associate Patient Safety Officer
San Francisco General Hospital and Trauma Center