Falls

BY: JOSHUA PEACOTT-RICARDOS

LEEANN YEE
STEPHANIE WONG
YZZA MAY SEBASTIAN

FALL

The National Database of Nursing Quality Indicators defines a fall

as
An unplanned descent to the floor, with or without injury to the
patient

Hospitalized patients are at risk for falls because:

Age-related changes

Urinary incontinence

Chronic Illness

Medications

Confusion

Hx of fall

Environment

Inadequate/improper use of equipment

Why Are Falls a Quality Issue?

According to the Department of Health and Human Services, 700,000

to 1,000,000 falls occur in the hospital EVERY YEAR

According to Hawaiis State Department of Health Emergency Medical

Services Injury Prevention System Branch, (2011) approximately
65,046 of elderly will fall each year in Hawaii and in 2010 we spent
$112 million in hospital medical charges for fall-related injuries among
older adults

Around 30% of these falls will result in a serious injury.

The cost of treating this 30% for their injuries is expected to reach $54.9
BILLION by the year 2020.2

Centers for Medicare and Medicaid Services (CMS) will not reimburse
hospitals for certain injuries caused by patient falls.

Falls are a patient safety issue and a financial burden to hospitals

Key Players Involved

Patient

Health Care Team

Nurses

Aides

PT/OT

Providers

Pharmacist

Lift Team

Quality Improvement Team

No One Walks Alone (NOWA)

What if every patient were treated as a fall

risk, regardless of diagnosis?

Key features of a NOWA protocol

Applies whenever a patient is out of bed,

including:

Transfer from bed to chair

Toileting

Ambulating

Transferring

Patient will be accompanied by STAFF, not

visitors, family, volunteers, etc.

Patient will receive education on NOWA

NOWA protocol

Kaiser San Diego implemented NOWA from Aug 2012 to Jun 2014. They saw
reduction of falls immediately after implementation.

NOWA

According to Salem Health, a hospital in Oregon:

Pre NOWA implementation: 20 falls and 2 with injury (over 7

months) post NOWA implementation: 7 falls and 0 with injury (over
7 months) for a 65% reduction in falls per the raw data. From a pre
and post look at falls per 1000 patient days: 2.4 falls/1000 pt days
vs 1.05 falls/1000 pt days. From this perspective, there was a
56.25% decrease in falls/1000 pt days from pre NOWA to post
NOWA.

Retrieved from: http://www.salemhealth.org/docs/default-source/oregon-nursing-researchquality/2015/onrqc-2015-no-one-walks-alone-fall-prevention.pdf?sfvrsn=2

How to Implement NOWA

PLAN
We predict this will reduce the total number
of falls, and in turn reduce fall related injuries.
Educate RNs and UAP, OT/PT, on NOWA
protocol. Its a continuous process. Education,
in-service, reinforcement, and involvement of
patient and family.

DO
Start by implementing on one unit (maybe
the one with highest incidence of falls so
easiest to see change?) Collect data on total
number of patients, number of hospital days,
and number of falls. Document whether falls
occurred in presence of staff member. If fall
occurs without staff member present,
discover why (patient did not follow
instructions, got out of bed without staff
knowing, staff careless, etc)

Study
Act
Analyze the data: compare data to baseline
If number of falls decreases, implement to
before program is implemented. Evaluate
other units. If not, look at what can be done
Monthly. Did falls decrease? Did staff comply differently? Maybe not apply to ALL units?
with program? Get feedback from staff on
difficulties.

References
Aging and Disability Resource Center Hawaii. (2013). Hawaii Falls Prevention State Plan. Retrieved
from https://www.hawaiiadrc.org/Portals/_AgencySite/2013Falls.pdf
Hospital Quality Institute. (2014). Falls no one walks alone (NOWA) kaiser permanente san diego.
Retrieved from http://www.hqinstitute.org/sites/main/files/file-attachments/
kaiserpermanente_san_diego_0.pdf
Kaiser Foundation Hospital. (2014). Fall prevention and management program policy no one walks alone
protocol.
Pearson, K. (2011). Evidence-based falls prevention in critical access hospitals. Retrieved from
http://www.flexmonitoring.org/wp-content/uploads/2013/07/PolicyBrief24_Falls-Prevention.pdf
Trump, N. (n.d.) No one walks alone fall reduction program. an innovative approach to falls. Retrieved from
http://www.salemhealth.org/docs/default-source/oregon-nursing-research-quality/2015/onrqc-2015-noone-walks-alone-fall-prevention.pdf?sfvrsn=2
US Department of Health and Human Services. (2013). Preventing falls in hospitals. Retrieved
http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtkover.html#Problem