Look at the patient falls chart on the bulletin board.
It's back to zero days since the last fall.
That's really disappointing, especially
when our CUSP Quality Improvement Project is
about using the electronic health record to identify
which patients are at risk for falls.
I agree.
You know, we've made much more progress on some of the
other safety defects that we've worked on as a team.
It's frustrating that we haven't been able to
decrease the number of falls.
We need to figure out how we can do better. But right now, let's
check in on Mr. Walton before morning rounds.
I need to take a good look at his chart because I
haven't taken care of him before.
I think he's been here for a couple of days.
And look here, it's right here on his record:
he's a fall's risk.
Look, he actually had a near fall yesterday.
Do you know anything about that?
No, I didn't hear a word about it.
Maybe we should ask Mr. Walton what happened.
Hi, Mr. Walton.
My name is Bev.
I'm the nurse who is going to be taking care of you today.
And I'm Allea.
I'm the nursing assistant working with Bev today.
How are you doing, Mr. Walton?
Oh, I'm doing okay.
I've been here a couple of days now.
I hope I can go home before too long.
We'll be making rounds as a full team with your
physician later this morning, and we can talk about
your discharge plan then.
Is anyone from your family going to be here?
We can talk with all of you together.
Yeah, my wife might be by later.
Okay, we'll want to speak with both of you together while
she's here.
And we noticed your chart says you almost fell yesterday.
Can you tell us what happened?
Well, yeah, it was late afternoon and my wife had
just gone home, and I really had to go to the
bathroom and I didn't want to bother anyone because I
know you're all so busy, so I thought I could get
up and go to the bathroom by myself.
Did you use your walker?
Well, I, I couldn't, I couldn't find it.
I try to keep it here by the bed, but I couldn't
see it, and I really had to go.
I'm really sorry about that, Mr. Walton.
And I see that your walker is over there.
How long has it been over there?
I think since yesterday.
I remember when my wife was visiting and her chair
was right by the bed here, and they brought my meal
tray in and put it on the table here, and they
probably pushed my walker over there to make more room.
Alright, Mr. Walton.
I'll put your walker right here beside your bed so you
can get to it easily, if you really need to use it.
But please, use your call button if you need to go to
the bathroom, okay?
Yeah, okay.
We'll be back in a little while to check on you, and
I'll also talk with the other nurses on the unit
about checking in with you more frequently to see if
you need to use the bathroom.
Okay, thank you.
You're welcome, Mr. Walton.
I'm glad that Abbey is our nurse manager; I feel
really comfortable talking with her about patient safety issues.
Yeah, she's very approachable and responsive to our concerns.
She would definitely want to know about Mr. Walton,
especially since it relates to patient safety.
Hi, Abbey.
I'm sure you have a zillion things going on
right now, but...
Always, but please come in.
Thanks.
Allea and I need just a couple of minutes of your time.
We have some concerns that we'd really like you to know about.
Oh, sure.
I always appreciate it when you come and tell me
what's going on.
You and the others are my ears and eyes out there.
So, what's up?
You know how we've been trying to cut down on the rate
of patient falls with our CUSP team?
Yes.
Well...
We learned some things that are pretty worrisome
when we went in to talk with Mr. Walton this morning.
We saw on his chart that he was identified as at
risk for a fall, but when we went into his room, we thought
'No wonder he almost fell.'
His walker was over in a corner, too far away from his
bed for him to get to it.
He said he didn't want to bother anybody, but he
really needed to go to the bathroom so he tried to
get up and go by himself without his walker.
It sounded like his walker was pushed in the corner
to make room to bring in his meal.
Then nobody moved it back.
Oh, I'm so sorry to hear that.
Well, you're exactly right.
The data that we have on falls shows that we still have
plenty of room for improvement, and I really
appreciate you for bringing this to me.
You've both made some really important observations.
I think there are ways that we can help
prevent falls for Mr. Walton and the rest of the floor.
You're right, Allea.
Abbey, don't we have a Learning From Defects
session coming up before the next CUSP meeting?
Yeah, you're right, we do.
I think this should be our topic because we've
already identified some possible causes, and Allea
and I have ideas for some solutions.
Can we talk about that with the group?
Absolutely.
That's a great idea.
Great!
Thanks so much.
Alright, you're welcome!
Thanks everybody for coming.
I know you're all busy, so I just want to say as the
leader of this group, I really appreciate you
making the time to be here.
It really does take all of us together, with our
different perspectives, to reach the goals of our CUSP team.
As a group, we've identified patient falls
as a primary area of focus for improvement on our floor.
The data show that we have the highest rate of
falls in the hospital, and our goal is to decrease that rate.
So what you're saying is we need to increase the
number of days between patient falls.
That's what we're tracking on the patient falls chart
on the bulletin board.
We've been working on this for a while and,
unfortunately, we haven't solved this problem.
Both of you are right.
We've discussed potential reasons why our floor
continues to have falls and near falls in our
Learning from Defects meeting a week ago,
and here are some of the interventions we've identified.
The first intervention is to tape an outline of the
walker on the floor to show where it should go.
A second is educating patients and their
families on falls prevention by developing a pamphlet.
A third is proper entry of patient information into
the EHR and ensuring that staff reviews the records regularly.
And a final intervention is ensuring that the
call button is within the patient's reach and
that the patient understands how to use the button
and understands its importance.
We already mark the EHR when someone is at risk for a fall.
The problem is we don't check the EHR regularly.
We should be reviewing the records
before we go in to see a patient.
You're right.
But can we shelve that topic?
I'd like to talk about this idea of a pamphlet.
If we had a pamphlet that describes things like tape
on the floor to mark where the walker should be or
asking patients to use the call button early when
they need to use the restroom,
that would really be helpful for patients and their families.
We could give the pamphlet to patients when they're
admitted to our floor and review it with them while
their family members are here.
I really like that idea.
If we put a taped spot on the floor, then everyone
will know where the walker belongs, including the families.
Because sometimes, they're the ones that move the walker.
Then we'll have to teach everyone, including the
dietary staff, about putting the walker back
where the walker belongs before they leave the room.
You know, as NAs, we round every 90 minutes.
As a double-check, we can make it part of our
routine to ensure that the walker is
actually in the taped area.
That's a great idea.
And if you can design the pamphlet, I can provide
the funds to get it printed.
You know, Abbey, you're always coming up with
great ideas for the staff to develop professionally
and contribute to the team.
Can you think of a staff member who may have an
interest in design and is also looking for some
professional development opportunities this quarter?
You know, maybe we could ask Jack.
I know he enjoys design, and he even made some of the
posters that you see around the unit.
He works three 12s, so he may have a couple
of hours available.
And I know he's looking to advance to a CNIII on our
clinical ladder, so this could provide him an
opportunity to work towards his professional
development goals.
Sounds good to me.
Well, you guys are great.
I really appreciate everyone's input.
These ideas sound like meaningful solutions.
I really hope they help us make more progress.
So, I'll talk to you next week about that.
That sounds good, thank you.
Hey, Abbey, do you have a second?
I just want to tell you, you're doing a great job
with the CUSP team, especially leading that
initiative on reducing patient falls.
Oh, thanks.
Our team is really excited about the progress that we're making.
120 days since the last fall.
You've really reduced the falls rate.
Well, I really appreciate you noticing that.
The team has worked really hard to make that happen.
We're tapping into some of Jack's other talents, and
we're grateful to you for providing funds so we could
print the pamphlet.
And I've noticed another area on our dashboard
you've addressed - your staff satisfaction has also increased.
You've really done a great job!
Well, the nurses have told me how much they
appreciate having the pamphlet to give to
patients and families when they come on our floor.
They enjoy teaching them about things like this
that really matter.
Well, I can see that you've improved patient safety,
you've developed your staff, you've engaged the
patients and their families all at the same time,
and you met your budget target.
While financial goals aren't our primary focus
in patient safety, they are important.
You've done a terrific job,
and I just want to thank you for your leadership.
Well thanks, Kathy.