A project involving seven hospitals has yielded fresh information on the causes of patient falls and possible solutions, The Joint Commission said in a new report.
The project was part of the Joint Commission Center for Transforming Healthcare preventing falls with injury project and involved seven U.S. hospitals using Robust Process Improvement, a TJC methodology that incorporates tools from Lean Six Sigma and change management. The hospitals studied fall injuries on their inpatient units, including four medical-surgical units, one medical oncology unit, a cardiology unit, and a medical-surgical/stroke/telemetry unit.
Each hospital identified the factors that most commonly led to falls with injury and developed solutions targeted to those contributing factors, which varied with each facility. They identified 30 root causes and developed 21 targeted solutions to address them.
The top 10 contributing factors for falls and falls with injury were grouped into six categories: 1) fall risk assessment issues, 2) handoff communication issues, 3) toileting issues, 4) call light issues, 5) education and organizational culture issues, and 6) medication issues.
The solutions developed for those problems were then pilot-tested with five additional hospitals for validation and solutions. TJC provides the results in the report “Preventing Patient Falls: A Systematic Approach from the Joint Commission Center for Transforming Healthcare Project,” available online at: http://bit.ly/2dVesJW.
