Background
4 SIs reported in AMU1 in first quarter of January 2021, with rising number of falls. 2 SIs on SSU all related to falls: key themes highlighted were poor documentation, delays in the timely management of falls and equipment issues, compliance with Baywatch
Initial Falls audit showing compliance of 40-45% with falls risk assessment and management of care plans paperwork
Aim: To reduce number of falls with serious harm by 50% by April 2022
i.e. (Reduce no of harms above moderate harm from 4 to 2, by December 2021 and 2 to 0, by March 2022
PDSA cycles: Testing Falls digital proforma and falls poster with staff.
Key learning:
IHI QI project score: 3.5/5, achieved our aim !
Patient involved in designing falls safety poster- Thanks to Ricah, RN !
Everyone on team was on board – consistency at huddles where we discuss risks of falls and give staff reminders daily
Key learning
Constantly on OPEL 4, busy unit with high turnover of 800 -1000 patients still managed to keep harms low - Learnt that it is important to accommodate the big picture and we applied a Safety II approach..
Felt really disappointed and despondent that we didn’t hit our Aim in August but then learnt to look at the big picture (1 SI vs 800- 1000 patients turnover)
Learnt it’s ok to fail and start again - the nature of QI is dynamic
Click on the image below to read and download the project poster
