“I need help in 230A! Mr. Johnson is on the floor!”
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Does your heart still sink when you hear a patient has fallen? We’ve gotten better at preventing falls, but we haven’t eliminated them. They remain one of the most common “incident” reports in hospitals. And did you know that adult behavioral health inpatients have more falls and fall-related injuries than patients on medical-surgical units?
In this month’s Cultivating Quality article, “Preventing Falls Among Behavioral Health Patients,” free until July 20, Stephanie Ocker and colleagues discuss their very successful falls-related interventions on an inpatient behavioral health unit. As they proceeded with their root cause analyses of recent falls, an unusual risk factor stood out:
“Patients frequently walked in the unit’s common area with bath blankets hanging around them and often trailing under their feet. When nurses would ask patients not to walk around with blankets to reduce the risk of tripping, patients would say they were cold.”
An unexpected solution born of a root cause analysis.
Instead of focusing only on improving fall assessments, staff communication, and workflow, the team discussed what could be done about their chronically cold unit. Their simple and very straightforward solution: purchase soft, warm sweat suits for patients! Not unexpectedly, this relatively inexpensive intervention (and big improvement over cotton hospital gowns) increased patient satisfaction as well.
In this article, Ocker and her colleagues not only showcase a very unit-specific solution to a falls problem; they highlight the value of a root cause analysis in exploring the reasons for a new problem. Read more about this thoughtful QI project in this month’s AJN.
Many nurses with age abstract from different situations that occur in the hospital and are not attached to patients. I am not one of these workers, and I worry about people. Old people often fall, lose their balance. We really cannot completely prevent this, but in the hospital this risk is reduced because there are handrails around the perimeter and many medical workers who are ready to help.