Guide Optimizing Outcomes! Error Prevention and Evidence-Based Practice with IV Medications

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A useful way to do this is by developing a clinical pathway. A clinical pathway is a structured interdisciplinary plan of care designed to support the implementation of clinical guidelines. It provides a guide for each step in the management of a patient and reduces the possibility that busy clinicians will forget or overlook some important component of evidence-based preventive care. An example of a clinical pathway detailing the different components of a fall prevention program is found in Tools and Resources Tool 3A, "Master Clinical Pathway for Inpatient Falls". This tool can be used by the hospital Unit Team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units.

This tool can be modified, or a new one created, to meet the needs of your particular setting. If you prepared a process map describing your current practices using Tool 2C , you can compare that to desired practices outlined on the clinical pathway. Hospitals have experienced local challenges in trying to implement best practices.

Has your hospital experienced any of the challenges listed below? This section of the toolkit will help to address these challenges. Universal fall precautions are the cornerstone of any hospital fall prevention program, because they apply to all patients at all times. Implementing universal fall precautions requires training all hospital staff who interact with patients, regardless of whether they are clinicians covered more in section 4. Implementation also requires that the importance of fall prevention become embedded into the hospital's culture covered in section 6.

Universal fall precautions are called "universal" because they apply to all patients regardless of fall risk. Universal fall precautions revolve around keeping the patient's environment safe and comfortable. Although the choice of which precautions to emphasize may vary by hospital, a good starting list adapted from the Institute for Clinical Systems Improvement guideline go to section 3. Universal fall precautions constitute the basics of patient safety. They apply across all hospital areas and help safeguard not only patients, but also visitors and staff in many cases.

Maintaining a safe and comfortable environment is the responsibility of the hospital independent of a patient's particular risks for falls, because failure to do so can put any patient at risk. For example, virtually any patient could slip and fall if there is a spill on the floor. Universal fall precautions should be performed from both the standpoint of the patient and the physical environment. For those precautions that require checking on the patient, such as making sure the patient's personal possessions are within reach, hourly rounding is an excellent basic strategy.

Hourly rounding is typically defined as hourly visits between 6 a. Hourly rounding can be carried out by a nurse alternating with a nursing assistant such as a certified nurse assistant, patient care technician, or nurse's aide. Patients are not disturbed if sleeping, except as needed to provide care. Tool 3B, "Scheduled Rounding Protocol," provides a scripted approach to a strategy that can be used during bedside rounds. Called the "4 P's" or "5 P's," it represents a set of items to mentally review when rounding on the patient.

For example, the 5 P's could be:. One benefit of hourly rounding is that it is proactive; it reduces patients' need to use the call light to ask for help and therefore decreases the number of unscheduled call lights that require response. These regular rounds allow many needs like toileting and access to drinking water to be met by staff who are scheduled to visit the patient's room.

Hourly rounding has been carried out in different ways by different hospitals. Despite its seeming simplicity, it requires careful planning to implement. Go to section 4 for strategies on implementing new care processes at your hospital. In addition to nursing staff, many different hospital staff members enter patients' rooms throughout the day, which provides additional opportunities to ensure that universal precautions are followed. Having a member of senior management periodically tour hospital rooms to talk with patients and see that their needs are being addressed is an excellent stimulus to frontline staff to continue their efforts.

To cover environmental safety, regular environmental inspection rounds with nursing staff and facilities engineers Tool 3C can be valuable. In between regular inspections, staff can use a hazard reporting form Tool 3D to alert the unit manager to items that require fixing. In addition to thinking about patient needs and environmental safety, remember to consider the interaction of the patient with the environment.

An environment that is safe for one patient may not be safe for another. For example, a bathroom door may be wide enough for an independent patient to enter but not wide enough for a patient with an assistive device, thereby putting the latter patient at risk. This is particularly important for patients who require assistance with transfers. If staff members are not trained in safe patient handling, a patient could fall or staff could be injured because appropriate assistive equipment was not used. A clinical pathway that illustrates appropriate application of safe patient handling principles Tool 3E, "Clinical Pathway for Safe Patient Handling".

Medication errors: Best Practices

The way that hospitals are designed is an important part of reducing fall risk. The Facilities Guidelines Institute www. Some design changes e. The Center for Health Design www. One hospital found that performing an environmental inspection identified stability problems with existing patient beds. The hospital was able to justify implementation of a bed replacement plan in the subsequent year. To read more about the evidence for improving hospital design, including safe patient handling, see:.

Universal fall precautions can be documented in many ways, including progress note templates in the chart and logs used for hourly rounding hourly rounding is described in section 3. Any documentation strategy should be carefully integrated into workflow, so as not to become just another charting task.

The rapid pace of activity in the hospital can be a barrier to implementing universal fall precautions. Patients are frequently transported on and off the unit for tests and procedures. In addition, patients may be required to change beds within the unit or be transferred to a new unit.

Every time a change occurs, universal fall precautions such as making sure the patient's call light is within reach and that the patient is oriented to his or her environment need to be reassessed. Another barrier to implementing universal fall precautions is that some precautions require patient understanding and cooperation. For example, patients may need to cooperate with using appropriate footwear or using the call light when they need help. Patients who do not know their own limitations may put themselves at risk for a fall despite the best efforts of hospital staff.

Assessing the patient for fall risks gives you the information you need to develop an individualized care plan. There are multiple risk factors for falls, and different patients may have different combinations of risk factors. These can change over time while a patient is in the hospital. To identify the risk factors most important to the patients on your unit or in your hospital, you need a system in place to ask the same key questions of each patient so that risks are not missed.

This can best be accomplished through a standardized assessment of fall risk factors. After universal fall precautions, a standardized assessment of risk factors for falls is the next step in fall prevention.


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By virtue of being ill, all patients are at risk for falls, but some patients are at higher risk than others. Assessment of risk factors for falls is a standardized and ongoing process with the goal of identifying patients' risk factors, which can then be addressed in the care plan. An assessment of risk factors for falls is a standardized process that uses an assessment tool. The tools evaluate several different dimensions of risk, including fall history, mobility, medications, mental status, and continence.

A tool could be a simple checklist of risk factors, or it could be more complex, depending on the needs of the hospital or unit. Because assessment is a defined task, clinicians can perceive that completing the assessment tool is all they need to do. The Unit Team can help staff understand that these assessment tools are only one small piece of the process. The risk assessment tools are meant to complement clinical judgment, not to replace it. Many other factors that are not listed in a typical risk factor assessment may be considered as part of clinical judgment. In fact, specialized wards may need to collect additional risk factors as part of their intake assessment.

For example, on geriatric psychiatry wards, because of the medications patients are taking, orthostatic hypotension may be an important fall risk factor go to Tool 3F for instructions on measuring and evaluating orthostatic vital signs. However, for consistency, we recommend that your hospital use a standard assessment tool throughout adult units in the hospital as a foundation on which additional unit-level risk factors may be added.

This permits staff floating across different hospital units to share a common and familiar tool. Assessment of risk factors for falls includes both the use of a standardized tool and an assessment of other factors that may increase risk of falls. Which other factors to consider beyond the standardized tool depend on clinical judgment and unit-specific policy.

Some tools that assess risk factors for falls also include a scoring system to predict risk for falls, and many facilities plan care according to the amount of risk according to high, moderate, and low risk, for example. The problem with using the risk score to plan care is that the care plan is not tailored to the individual patient's risk factors. For example, two patients deemed "high risk" by score might have different risk factors; one could have delirium, and the other could have impaired gait. The responses to these risk factors need to be different. Trying to apply the same care plan to all "high risk" patients may distract staff from implementing the elements of the care plan that actually address each individual patient's risk factors.

For these reasons, we think the most important application of an assessment tool is to identify fall risk factors for which care plans can be developed. Because it takes time for a hospital's culture to move away from relying on a summary score, we provide the scales in full here, but we do not recommend excessive focus on the score. Both scales have established reliability and validity. When used correctly, they provide valuable data to help plan care. Because each hospital setting is unique, we do not take a position as to which scale you should use.

Also, these scales do not cover all key fall risk factors, so for your unit's needs, you may have to supplement these tools with additional assessment items, such as those found in some of the other tools covered in this section. The key point is to ensure that a standard scale is used throughout adult units in the hospital, with additional risk factors assessed as needed for specific units or as suggested by clinical judgment. Strategies for reviewing medications will depend on your hospital but may consist of a pharmacist reviewing medications for patients with other risk factors or a nurse checking the patient's medications against a standard list and referring patients with a high-risk medication to a pharmacist.

In either case, the pharmacist will make recommendations back to the medical team regarding medications to discontinue or doses to change. How should risk factors be assessed in pediatric populations? The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in differentiating the level of risk for hospitalized children.

Consider performing a fall risk assessment in general acute care settings on admission, on transfer from one unit to another, with a significant change in a patient's condition, or after a fall. For patients with longer lengths of stay, performing a fall risk assessment at some regular interval may be valuable.

However, the optimal frequency of risk assessment is unclear and may vary by unit. The accuracy of a risk factor assessment tool depends on the person using the tool. Experience has shown significant variability among untrained staff even when evaluating the same patient. The results of the fall risk factor assessment need to be trustworthy; otherwise, they will be ignored. Therefore, training in how to complete the risk factor assessment is needed.

Ten key elements of medication use

In addition to the module, training should include real cases where the provider conducts an assessment. Mental status and gait parameters require actual assessment of a real patient as opposed to a chart review by itself. Knowing which patients have risk factors for falls is not enough; you must do something about it.

Care planning guides what you will do to prevent falls. Once risk assessment has helped identify patient risk factors, care planning should match the identified risks. This includes planning for any risks found on the risk factor assessment tool, such as mobility challenges, medications, mental status, and continence needs. It also includes planning around a patient's personal risks that may not have been captured by the assessment tool. Fall prevention care planning is a process by which the patient's risk assessment information is translated into an action plan to address the identified patient needs.

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These are the patient-specific actions that, in addition to the universal precautions described in 3. Care planning's specific purpose is to identify specific care practices that will be implemented so that the patient is less likely to fall during the hospitalization. Care planning accounts for multiple factors that pertain to the patient's problems, and the clinician therefore must synthesize multiple types of clinical data rather than just relying on one specific piece of information.

Because each patient has a unique risk profile that needs to be integrated with care for the condition that caused hospitalization, the care plan should be individualized for each patient. A carefully written care plan is a document that ensures continuity of care by all staff members.

Evidence-Based Practice

In addition, it can keep the patient safe and comfortable and can be used to educate the patient and family prior to discharge. The care plan is an active document. It needs to incorporate the patient's response to the interventions as well as any changes in his or her condition. The care plan indicates specific actions that should, or should not, be performed. All care planning needs to be individualized to fit the patient's needs. Each risk factor should have a corresponding plan of care. There are many interventions available to prevent falls and fall-related injuries that you can implement based on the patient's specific risk factors.

Below we list some of the major categories, by risk factor, that you can consider in your care plan, with electronic resources where appropriate. Trained nurses or physicians can carry out a delirium assessment. If the patient is found to be delirious, a medical provider should evaluate the patient for causes, such as infections, medications, and electrolyte imbalances.

But it is more effective to prevent delirium than to treat it. Delirium prevention may be an important part of the care plan for units that have patients at high risk for delirium e. For cognitively impaired patients who are agitated or trying to wander, more intense supervision e. These patients should have their medications reviewed, as medications can both contribute to agitation as well as help calm patients whose agitation is a threat to themselves or others or is interfering with the delivery of necessary care.

We do not recommend bed alarms for the purpose of fall prevention in cognitively impaired patients. Unless the patient can be rescued rapidly after the bed alarm goes off, the patient may be able to exit the bed well before anyone can come to help. One large trial of bed alarms failed to show a benefit for prevention of falls. Some hospital units have designated areas for patients at high fall risk. These areas have enhanced staffing to observe patients more closely. One hospital implemented this strategy using safety zones, which consisted of four patient rooms in each unit with one dedicated staff member responsible for those patients.

The staff member checks on the patients every 15 minutes. These rooms are designated for cognitively impaired patients requiring 1 closer supervision, and 2 specialty equipment and activities. Safety zone room equipment includes low beds, mats for each side of the bed, night light, gait belt, and a "STOP" sign to remind patients not to get up. This model was originally implemented as a less costly alternative to the hospital's patient sitter program. The hospital reports the program has been successful in reducing fall rates and improving patient and family satisfaction.

Patients with impaired gait or mobility will need assistance with mobility during their hospital stay. All patients should have any needed assistive devices, such as canes or walkers, in good repair at the bedside and within safe reach. If patients bring their assistive devices from home, staff should make sure these devices are safe for use in the hospital environment. Even with assistive devices, patients may need help from staff for mobility. To read more about the Hospital Elder Life Program, which offers strategies for developing a volunteer-based mobility program, go to www.

Patients with frequent toileting needs should be taken to the toilet on a regular basis, via a scheduled rounding protocol for example, go to Tool 3B. Patients on high-risk medications go to Tool 3I, "Medication Fall Risk Score and Evaluation Tools" should have those medications reviewed by a pharmacist with fall risk in mind.

Recommendations made to the treating provider for discontinuation, substitution, or dose adjustment. If a pharmacist is not immediately available, the treating provider should carry out the medication review. The medication review may sometimes indicate that the patient needs to stay on a medication that increases the risk for falls because the benefits outweigh the risks, but the important point is that fall risk was considered. In addition, each hospital may need to develop its own approach to pharmacist-physician communication around medications to ensure that physicians carefully consider pharmacists' recommendations.

Units with a high proportion of patients on medications that cause orthostatic hypotension, such as psychotropic medications, may want to use a protocol for checking and reporting orthostatic vital signs go to Tool 3F. Finally, the patient and patient's family should be alerted and educated about fall risk and steps to prevent falls when the patient is taking these medications. Patients with frequent falls should have their injury risk assessed.

This assessment should include checking for a history of osteoporosis, including prior low-trauma fractures or osteoporosis noted on a bone mineral density test. Although the effects are long term, treatment for osteoporosis should be considered if the patient is not already on treatment. Also, the patient's physical environment should be reviewed to reduce the risk of injury e. In hospital units known to have a high prevalence of patients at risk for injury after a fall, consider making an injury risk assessment part of the admission evaluation.

Patients and their families should understand the patient's fall risk and how the proposed care plan addresses this risk. Specific aspects of the care plan that patients and families can help implement should be identified. If learning needs have been identified, teaching to address knowledge gaps can occur. Use of educational resources, such as written materials appropriate to language and reading level go to Tool 3L, "Patient and Family Education" , can augment but not replace instruction.

Patients and their significant others need to understand the potential consequences of not following a recommended prevention care plan as well as feasible alternatives and possible outcomes. Every patient has the right to refuse the care designated in the care plan. In this case, staff are responsible for several tasks, including:. One hospital trains volunteers to provide fall prevention education to patients. Each volunteer spends minutes visiting each patient every Monday, Wednesday, and Friday to review the fall prevention handout.

This education is supplemental reinforcement and does not replace education provided by the nursing staff. Document fall risk factors, and interventions to address those risk factors, in the care plan. Documentation of care planning ensures continuity of care and staff knowledge of what should be done for the patient.

Most hospitals choose to have a dedicated care plan form within the medical record. The care plan helps all staff members to be aware of a patient's risks. Consider the following strategies to enhance awareness of fall risk factors and appropriate documentation:. Because many of the risk factors for falls are important for other aspects of good care e. That way, you only have to collect and document the information once. Remember that while medical record documentation is necessary, it alone will not be sufficient.

Communicating the patient's risk factors should occur orally at shift change, and by review of the written material in the medical record or patient care worksheet. The oral shift handoff should include any change in fall risk factors during the shift, including relevant medication changes, and should incorporate findings from hourly rounding. Patients demonstrating particularly high risk behaviors can be discussed as part of the unit's safety huddle or safety briefing.

A safety huddle is a short, informal meeting to cover issues related to patient safety. The safety huddle can be enhanced by a standard report preferably gathered electronically that summarizes which patients on the unit have which risk factors for falls. In addition to shift change, medical rounds are an opportunity for interdisciplinary communication. For example, pharmacists may attend these rounds and provide an update to medical providers about medications that put the patient at higher risk of falls. Or, if attendance on rounds is not possible, pharmacists can place recommendations to change drug therapy as a consult note in the medical record.

Mobility programs that combine services of nursing and rehabilitation personnel offer another example of interdisciplinary communication and collaboration. Nursing assistants mobilize patients at risk for deconditioning who are in the hospital for non-mobility-related reasons. Physical or occupational therapists see patients with a need for skilled care or with weight-bearing limitations. Remember that the fall prevention component of the care plan needs to be updated periodically to be accurate.

The care plan needs to be reassessed when a patient's risk factors are reassessed and are found to have changed. Typically this is when a patient changes units, has a change in health status, or has a change in medication associated with increased risk of falls.

These updates also need to be followed up by a change in your actual care practices for the patient. Sometimes, putting together all the discrete parts of a care plan based on patient risk factors can be akin to putting together a puzzle. It takes time and the ability to see the whole picture, and it definitely requires patience and skill. There are many potential barriers to accurately completing care planning. Some that should be considered include:.

Despite our best efforts, patients will nonetheless fall. Some may even sustain an injury. When a fall happens, you will need to carefully assess the patient for any injuries in a systematic way.


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After the patient's needs are attended to, you need to document your findings in the medical record and complete an incident report. In this section we highlight some elements of a careful clinical review for injuries and also discuss conducting a root cause analysis to understand the causes of the fall. An understanding of the events surrounding a fall can inform the care plan for the patient who fell, as well as guide ongoing quality improvement efforts at the unit level.

Using data on falls to monitor your improvement efforts is discussed in more detail in section 5. A postfall clinical review is a structured way to collect information after a fall. The clinical review aims to determine whether there are injuries or other complications Tool 3N, "Postfall Assessment, Clinical Review ".

The clinical review focuses on immediate risk of injury or complications. Depending on the type of fall and patient comorbidities, including clotting disorders and use of anticoagulants, the clinical review may include assessment for injury, serial neurologic exams, and a fresh fall risk factor assessment.

The new assessment will include medication review and ordering of laboratory tests. Root cause analysis is used in organizations to evaluate and understand what problems contributed to error or undesired outcomes. After a fall, you will collect data to reconstruct the event and determine the causes of and contributing factors to the fall Tool 3O, "Postfall Assessment for Root Cause Analysis".

The data collection will obtain information that may help prevent the next fall in this patient or future patients. The postfall assessment for root cause analysis captures information from the patient, staff, and other witnesses about how the fall occurred. For more on root cause analysis, go to section 5. Many components of the clinical review and root cause analysis overlap. For example, understanding the circumstances of the patient's fall can assist in assessing the patient for injuries, while also being important for understanding potential causes.

You may need to adapt Tools 3N and 3O to your hospital's specific needs. Documenting and communicating the clinical review are critical to the patient's safety, because a medical provider may need to take action based on the assessment, such as ordering lab tests or imaging studies or changing medications.

In cases of falls with significant trauma, the patient may need to be taken to surgery. An oral handoff to the treating medical provider is therefore essential. Careful documentation and communication of your root cause analysis are critical to preventing future falls in the same patient.

For example, if a patient was given a sedative overnight for insomnia and then fell due to being drowsy, the entire treating team including nursing, pharmacy, and medical provider needs to know what happened. That way, they will not prescribe the sedative again to that patient or future patients in similar circumstances. After a fall occurs and the patient's root cause analysis is complete, a safety huddle go to section 3. With frequent handoffs between hospital personnel, whether it be nursing staff who change shift every 8 hours, or hospitalists who rotate every week and have separate night or weekend coverage, communication is critical.

The care plan discussed in section 3. If applicable, the patient's risk factor profile can also be updated electronically by a designated member of the unit team to reflect the recent fall and any new risk factors that were discovered. For more information about what information should go into the hospital's incident reporting system, go to section 5. Performance of postfall assessments, whether for clinical review or root cause analysis, may be improved by having a standard protocol and ensuring that this protocol is easily accessible to staff on the unit.

Also, the information gathered on the assessment tool should contain all the information needed to file an incident report go to section 5 so that information does not need to be gathered twice. In settings where a medical provider makes scheduled rounds, having a nurse or pharmacist join rounds to discuss potential culprit medications related to the fall may improve the assessment process.

A modified version of the tool used in this study is presented as Tool 3O. In section 3, we have outlined best practices in fall prevention that you can use to improve your fall prevention program. Research evidence suggests that your program is most likely to succeed when it addresses multiple components, including universal precautions section 3. However, it may not be possible to tackle all these elements at once.

In addition, you may want to include additional items beyond what is discussed here. Some of these items can be identified through the use of additional guidelines go to section 3. In addition to creating a program that is tailored to your hospital, you will need to customize the fall prevention program to each unit due to patient acuity and specific individual circumstances. Thus, it is important to identify fall risk factors that are more prevalent on each specific unit.

For example, a neurology unit may have a high proportion of cognitively impaired patients requiring closer monitoring. A rehabilitation unit may have a high number of patients with mobility problems. Other units may have patients whose needs fluctuate rapidly or involve frequent patient transport. These include the emergency department, observation units for patients staying less than 24 hours in the hospital, and radiology.

In addition, pediatric patients have special assessment tools, as discussed in section 3. Examples from some hospital units addressing fall prevention. Note that some of these examples include activities that may be applicable to other units as well.

A number of guidelines have been published describing best practices for fall prevention in hospitals. These guidelines can be important resources for improving fall prevention programs. Once you have read through this section, use the checklist for best practices to monitor your progress on completing the activities that have been described here.

The user assumes all risk for use of the materials. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients. Ann Intern Med ; 10 National Patient Safety Agency, "Essential care after an inpatient fall. Search ahrq. Latest available findings on quality of and access to health care. Funding Opportunity Announcements. Preventing Falls in Hospitals 3.

Which fall prevention practices do you want to use? Previous Page Next Page. Preventing Falls in Hospitals. Are you ready for this change? How will you manage change? How do you implement the fall prevention program in your organization? How do you measure fall rates and fall prevention practices? How do you sustain an effective fall prevention program? Tools and Resources. Team members should reach consensus on the following questions: Which fall prevention practices should you use? Which universal fall precautions should be applied throughout the hospital?


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How should a standardized assessment of fall risk factors be conducted? How should identified risk factors be used for fall prevention care planning? How should you assess and manage patients after a fall? How can your hospital incorporate these practices into a fall prevention program? Some factors that make fall prevention challenging include: Fall prevention must be balanced with other priorities for the patient.

The patient is usually not in the hospital because of falls, so attention is naturally directed elsewhere. Yet a fall in a sick patient can be disastrous and prolong the recovery process.

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