A Root Cause Analysis‐Driven Initiative to Reduce Hospital Falls

1Northwestern University, Chicago, IL
2Northwestern Memorial Hospital, Chicago, IL
3Northwestern Memorial Hospital, Chicago, IL

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 192


Falls are a high‐risk, high‐volume, and high‐cost challenge for hospitals. As part of the 2009 national patient safety goals, the Joint Commission emphasized the need to reduce the risk of harm resulting from falls with falls reduction programs. Findings from root cause analyses from falls at our academic medical center identified 3 areas that contributed significantly to falls: lower‐extremity weakness, mental status changes, and medication effects. Gaps in our current risk assessment processes in these 3 areas were addressed.


Along with implementing a standard of nursing practice for falls prevention, a multi‐disciplinary team was organized lo develop systems to address 3 main risk reduction strategies: assessing functional mobility, identification of delirium, and monitoring medications that may conlribute to falls.


A multidisciplinary approach was developed on each unit consisting of nursing, hospitalists, and pharmacists. The team goal became to use critical thinking through enhanced assessments of functional status, mental status, and medication review. On admission, all patients had a nursing assessment of functional mobility focused on lower‐extremity strength. Patients with weakness were targeted for closer monitoring as well as behavioral and environmental interventions. A focus on early identification of patients with delirium was undertaken with the introduction of validated tools. A Short Portable Mental Status Questionnaire (SPMSQ) was conducted on admission (establishes baseline cognition}, and the Confusion Assessment Method (CAM) was done every 12 hours (monitors for acute change and delirium) Changes in mental status detected from baseline were documented and highly visible in the EMR. Nursing was encouraged to call hospitalists To evaluate patients to address treatable causes. Medications that were commonly associated with patients with falls were identified in our pharmacy database. Electronic triggers were initiated for physicians each time they ordered these high‐alert medications. A new hospitalwide training program focused on patient safety was developed regarding these 3 improvement areas. After implementing the program, falls decreased from an average of 3.07 to 2.42 (per 1000 patient‐days) over an 18‐month period.


Thorough analysis of our institution's fall trends helped lo define the problem, create improvements, and structure education. Functional mobility, mental status changes, and medication effects were incorporated into the previous falls risk assessment and led to an improvement in fall rates at our academic hospital. Along wilh current risk reduction strategies, hospitals should address these 3 areas to reduce falls.

Author Disclosure:

H, Shah, none; M, Streelman, none; B, Gobel, none.

To cite this abstract:

Shah H, Streelman M, Gobel B. A Root Cause Analysis‐Driven Initiative to Reduce Hospital Falls. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 192. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/a-root-cause-analysisdriven-initiative-to-reduce-hospital-falls/. Accessed March 30, 2020.

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