Authors (including presenting author) :
Shum TL, Hung PC, Wong WM, Leung SH, Wong SB
Affiliation :
Department of Medicine, Haven of Hope Hospital
Introduction :
Patient safety is the priority in health care system, however patient falls are the most frequently reported adverse event in hospital. In the first four months of 2018, it is quite alarming that there were seven patient fall incidents with severity index ranging from 1-3 in Medical ward in Haven of Hope Hospital despite of comprehensive fall prevention measures taken since admission. The post-fall investigations or even prolonged hospitalizations have contributed a lot in costing. Therefore, the enhancement program on prevention of patient fall named “ALERT” Program has been implemented.
Objectives :
1. To reduce the number of patient fall incidents 2. To minimize the severity of patient fall injury 3. To engage staff and care-givers in patient fall prevention
Methodology :
A working group has been developed to propose a systematic program to reduce patient fall incident since April 2018. The name of “ALERT” program was from the first letter of the subheading and showed as follows: (1)Analysis, Assess and Aware -Analysis hidden reason of fall incidents -Assess fall risk and aware cognitive impairment -Relocated Install flashing light of fall alarm pad to nursing station; (2)Low harm and low rate of restraint -Provide restraining workshop for health-care-workers to prevent overuse of restrainers and minimize the harm -Implement 5S to ensure safe and tidy environment; (3)Enhance communication with multi-disciplinary team -Handover high fall risk cases to team nurse of next shift -Identify high fall risk cases with labelling outside the cubicle -Well document fall preventive measures in high fall risk case; (4)Reinforce fall prevention to patient and their carer -Collaborate with multi-disciplinary to provide fall prevention education to patients and their carers; (5)Timely patrol and checking -Promote fall prevention round by duty-in-charge twice per day to reassess the preventive measures -Check functioning of alarm system by PCA twice per day
Result & Outcome :
After program implementation, the fall rates have decreased significantly from 1.55 to 0.43 (per 1000 occupied patient bed day) and the severity index ranged within 1-2. Meanwhile, number of restrained patients has reduced from 7.60 to 4.12 per day gradually. Most importantly, the “ALERT” Program successfully enhances staff and carers’ awareness and attention on fall management.
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