2063. Reducing Falls and
Injuries Due to Falls in the VA System
PD Mills, Dartmouth Medical School and Field Office, VA National Center for Patient Safety, J Waldron, Field Office, National Center for Patient Safety, PA Quigley, Patient Safety Center Inquiry, VISN 8, University South Florida Nursing and University of Phoenix, Nursing Health Sciences, E Stalhandske, VA National Center for Patient Safety WB Weeks, Dartmouth Medical School, VA Quality Scholars and VA National Center Patient Safety
of research into practice is needed to improve organizational performance.
We wanted to evaluate a translation program designed to reduce inpatient
falls and injuries.
teams completed an eight-month facilitated quality improvement effort, during
which time teams reported baseline and monthly patient fall rates (falls per bed
day of care) and major injury rates (major injuries per 100 falls).
We used paired t-test analysis to determine whether fall and injury rates
improved, surveys to assess team characteristics, ANOVA to identify team
characteristics that were associated with success and paired t-test analysis to
examine changes in team characteristics over time.
Results: While the
overall fall rate decreased only slightly during the effort (6.84 to 6.42), the
overall major injury rate dropped 62 percent, from 2.14 major injuries per 100
falls at baseline to 0.82 major injuries per 100 falls at project completion
(paired t-test p = 0.097). This
represents an average reduction of 40.9 major injuries per month. Top performers
turned in early progress reports (ANOVA, p=0.01), reported more staff support
(p=0.001), stronger leadership (p=0.04) and better conflict management skills
(p=0.03). By the second learning session more teams reported a better
understanding of team members (paired t-test, p =. 06), a more systemic
perspective (p = .04), and more data collection from patients (p = .04).
Virtually all teams reported learning new ideas and methods, and a belief that
the project added value to their facilities. Most teams also reported that they
used information from other teams and shared information with others. Toileting
interventions, use of signage to identify high-risk patients, environmental
interventions, post-falls assessments, use of hip-pads, and staff education
produced the greatest reductions in major injury rates.
Conclusions: The project
was successful at reducing major injuries and was perceived as helpful by teams.
Limitations include observational design, potential selection bias, and
lack of follow-up data.
Impact: Translation of research into practice can be facilitated by organized, team-based quality improvement initiatives. In addition to enhancing patient safety, these initiatives may be cost-effective: the decrease in major injury rate represents a monthly savings of between $667, 569 and $765, 934.