PATIENT FALL RISK

PREVENTION,MANAGEMENT &
CONTROL
(RCA & ACTION PLAN)
 1. OVERVIEW
A. PATIENT FALL OVERVIEW
B. DATA ANALYSIS

2. PROBLEM IDENTIFICATION - RCA

A. GENERAL HOSPITAL FALL WITH AND WITHOUT INJURY FISHBONE

CONTEXT
B. COMPLICATIONS

CONTENT 3. AIM OF THE INITIATIVE

4. FALL PREVENTION: TOOLS AND STRATEGIES – ACTION

RECOMMENDATION
A. STANDARDIZED APPROACH
B. KEY MEMBERS IN FALL PREVENTION PROGRAM
C. FALL RISK PREVENTION,MANAGEMENT AND CONTROL

5. SUMMARY : IMPROVEMENT METHODOLOGY

1. OVERVIEW
A. PATIENT FALL OVERVIEW

FALL is a serious health issue and often cause patient injury A fall without injury is still a FALL.

ASSISTED FALLS ARE:

Unexpected change in position that causes a person to land on • Staff intervenes
an object or floor. • Break patient fall
• Ease patient to floor

It can happen when other people are present or no one is Many falls are preventable and manageable
there.
 B. DATA ANALYSIS

OCCURENCES OF PATIENT FALL 2021 PATIENT FALL OCCURENCES

IN KSMC PER MONTH IN 2021 IN EACH HOSPITAL
24
12 25

NUMBER OF OCCURENCES
NO OF FALL PER MONTH

10 10 10
20
8 8
15
6 6 6
8
10 7
4

2 5 1
0
0 0 0
JAN FEB MAR APR MAY JUN ... D ...
IC U
AN C
C
TR ER AK
2021
G
H
T
&
D
IA AT
M
M PE
FIG. GRAPH NO. 1 FIG. GRAPH NO. 2

Currently, there is a total of 40 patient fall occurrences in KSMC since January 2021 to June 2021, categorized in
monthly (fig. graph no. 1) and department data (fig. graph no. 2).
B. DATA ANALYSIS

FALL
PATIENT FALL PER INDEX WITH
PATIENT FALL DESCRIPTION
INJURY:
6 OC-
CUREN
37 CES
OCCURENCES OF PATIENT FALL

40
35
30
25 FALL
WITH-
20 OUT
15 IN-
JURY:
10 3 34 OC-
FIG. GRAPH CUREN
NO. 4
5 CES

0
SEVERITY INDEX 2 SEVERITY INDEX 3

FIG. GRAPH NO. 3

Currently, there is a total of 40 patient fall (fig. graph no. 3) occurrences in KSMC since January 2021 to June
2021, categorized in fall description (fig. graph no. 4) ,
2. PROBLEM IDENTIFICATION
A. KSMC PATIENT FALL WITH AND WITHOUT INJURY FISHBONE
DIAGRAM
● Staff Heavy Workload
● Flooring structures ● Incomplete staff endorsement for the ● High patient acuity
● Unfamiliar environment to patient high risk fall score ● Training for transfer
● Not well lit rooms ● Incomplete staff documentation of ● Lack of staff
● No call alarms in the bathrooms
the staff about the fall risk score ● Lack of staff monitoring and follow up
● Distant locations of comfort rooms
● Multidisciplinary team’s knowledge ● Update for staff knowledge in policy and
● Common toilet for all patients in a unit
● theories about fall
Slippery floors about the fall risk of the patient ● Few staff adhere to use fall risk prevention
● Water spills ● No fall prevention awareness for the tools like sticker and ID band
relative and patients ● No cleaner available

ENVIRONMENTAL  
MANPOWER
FACTORS METHOD FACTORS HIGH
FACTORS
PATIENT FALL
MACHINE/ MATERIAL PATIENT INTRINSIC
FACTORS
MEASURE/CONTROL
FACTORS
RATE
FACTORS
GERIATRIC & PEDIATRIC PATIENTS
● Non- working call bell alarm in the
units ● Intervention guide for fall risk GERIATRIC PATIENTS PEDIATRIC PATIENTS
● High level of bed prevention (adult & pedia) ⮚ Mentally challenge/cognitively ⮚ No attendants
● Unraised side rails ● impaired individuals ⮚ Stressed mother
Limited Fall risk band
● Over reaching of patients to over bed ⮚ Gait instability ⮚ Unknowledgeable
● Unavailable Non-skid slipper ⮚ Delirium low GCS attendant about the
table ● Fall risk sticker on patient chart ⮚ History of previous falls fall prevention
● Un-braked beds ⮚ Visually impaired
● Unavailable night light   ⮚ Multimorbidity patients
● Unavailability of handrails/trapeze ⮚ Use of medications (anticonvulsants,
for patients tranquilizers, antihypertensive)
● Limited signage for patient’s bed ⮚ No patient attendant
⮚ Patient restraints
⮚ Ongoing IV fluids to patients
⮚ Unstable vital signs : hypotensive
⮚ Bone disorder
 
B. PATIENT FALL COMPLICATIONS

INCREASE HIGH POOR OUTCOME

LENGTH OF STAY HOSPITALIZATION TO THE PATIENT
COST SIDE
3. Aim of the Recommended Action
Guided by the KSMC policy, MPP-KSMC-054-V5:
❖ To have a blueprinted outline of actionable steps in the organization
which sustain improvement to reduce patient fall morbidity and
mortality;
❖ To improve KSMC clinical dashboards (quarterly & monthly) for
patient fall;
❖ To focus on overcoming the challenges associated with developing,
implementing, and sustaining a patient fall prevention program over
KSMC through the collaboration of the all involving parties.
4. PATIENT FALL PREVENTION: TOOLS AND STRATEGIES
ACTION RECOMMENDATION
A. Standardized Approach

PATIENT FALL COLLABORATION PATIENT FALL

WITH OTHER
PREVENTION & PARTIES TRAINING PREVENTION FOLLOW UP
MANAGEMENT AND EDUCATION BEDSIDE (Through leadership, commit to annual
(Implement & utilize
form/methods/materials for success.
(PATIENT,ATTENDANTS AND
STAFF) ALERT TOOLS education and assess competency
training to the staff)
Team members must understand roles (Building a culture of accountability and (Support staff initiative to reduce falls
& responsibilities.) safety to improve quality of care.) in the hospitals
PATIENT FALL PREVENTION: TOOLS AND STRATEGIES
B. Key Members in Patient Fall Prevention Program Proposal
(Involving Parties)

Nursing
PHYSICAL
Education PHYSICIAN
THERAPIST
team

NURSING :
Maintenance PATIENT &
STAFF &
team ATTENDANTS
LEADERS
 PATIENT FALL PREVENTION: TOOLS AND STRATEGIES
C. PATIENT FALL RISK PREVENTION,MANAGEMENT AND INTERVENTION CONTROL

PATIENT &
RELATIVE
RECOMMENDED
EDUCATION ACTION
BEDSIDE (TEACH BACK LOOK LIKE
HEALTHCARE
APPROACH,
ALERTS AND BOOKLETS/PAMPHLETS/ TEAM
TOOLS HANDOUTS)
ALERTNESS
The FALL RISK (CALL AND
BELL/SIGNAGES/SIDERAILS/L
PREVENTION, EVEL OF BED) READINESS
MANAGEMENT model (DOCUMENTATION, LEADERSHIP
ROUNDS, NCP, ENDORSEMENT,
TEAMWORK)

PATIENT FALL
PREVENTION
INCREASE
ENVIRONMENTAL
PROTECTION and MANPOWER
MANAGEMENT RATIO
(LIGHT & FLOORING
MAINTENANCE)
(IMPROVE NURSE TO
PATIENT RATIO HANDLING &
DELIVERING HIGH QUALITY
CARE)

PATIENT FALL RISK

CONDITION ASSESSMENT
(MORSE/HUMPTY
(INTRINSIC FACTORS) DUMPTY)
5. SUMMARY : IMPROVEMENT METHODOLOGY
A. FOCUS PDCA

PLAN DO
• TO DECREASE FALL RATE PATIENT FALL PREVENTION:
TOOLS AND STRATEGIES
ACTIVITIES
FALL RISK
PREVENTION,MANAGEMENT
AND CONTROL

CHECK
ACT FOR THE RESULTS
THROUGH ACCOMPLISHED
OVAR or INCIDENTAL
REPORTS & DASHBOARDS
THANK YOU!