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Reducing falls rate on a dementia assessment ward: can small changes make a difference?

Reducing falls rate on a dementia assessment ward: can small changes make a difference?
Reducing falls rate on a dementia assessment ward: can small changes make a difference?
Aim: to reduce the rate of falls in Brooker Organic

Objectives: To collect data on falls incidence and description events of every fall based on the incident reports; to actively engage ward staff throughout the project; to implement sustainable changes to practice to consistently reduce the rate of falls on the ward.

Methods: the review of post-falls incident reports alongside staff engagement activities informed the implementation of two changes to practice on the ward: (1) ward staff were instructed to write the date of the last fall on top of every patient clinical notes on a daily basis; and (2) prompts to facilitate a detailed post falls review were added to the weekly ward round paperwork. A statistical process control chart was used to monitor the rate of falls 6 months before and after the implementation of these changes to practice.

Results: these two strategies were implemented in June 2017. By July 2017, all patients had the date of their last fall recorded in their clinical notes. This was reviewed in March 2018 and adherence to this strategy remained 100%. Further, it had been expanded on spontaneous staff initiative to another ward. Falls continue to be discussed on weekly ward rounds. The statistical process control chart showed a reduction in the rate of falls from 3.80 to 1.76 per 100 occupied bed days.

Conclusion: changes to practice and improvements in care can be successfully implemented and sustained when frontline staff are empowered to make decisions based on routinely collected clinical data. The increased awareness of falls amongst staff and prompt multi-disciplinary reviews post falls may have contributed to a reduction in the rate of falls on the ward.
Goncalves, Ana Carolina, Vieira
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Demain, Sara
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Marques, Alda
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Samuel, Dinesh
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Belward, S.A.
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Legg, K.
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Meredith, R.
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Scaddan, L.
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Howard, S.
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Marshall, T.
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Jeffery, D.
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Wharam, H.
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Goncalves, Ana Carolina, Vieira
ecb4863c-186b-4ecd-abac-3745fa5fcf30
Demain, Sara
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Marques, Alda
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Samuel, Dinesh
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Belward, S.A.
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Legg, K.
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Meredith, R.
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Scaddan, L.
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Howard, S.
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Marshall, T.
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Jeffery, D.
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Wharam, H.
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Goncalves, Ana Carolina, Vieira, Demain, Sara, Marques, Alda, Samuel, Dinesh, Belward, S.A., Legg, K., Meredith, R., Scaddan, L., Howard, S., Marshall, T., Jeffery, D. and Wharam, H. (2018) Reducing falls rate on a dementia assessment ward: can small changes make a difference? Wessex Safety, Quality & Improvement Conference 2018: Culture: How it impacts on Patient Safety and Quality Improvement, Novotel, Southampton, United Kingdom. 08 Oct 2018.

Record type: Conference or Workshop Item (Other)

Abstract

Aim: to reduce the rate of falls in Brooker Organic

Objectives: To collect data on falls incidence and description events of every fall based on the incident reports; to actively engage ward staff throughout the project; to implement sustainable changes to practice to consistently reduce the rate of falls on the ward.

Methods: the review of post-falls incident reports alongside staff engagement activities informed the implementation of two changes to practice on the ward: (1) ward staff were instructed to write the date of the last fall on top of every patient clinical notes on a daily basis; and (2) prompts to facilitate a detailed post falls review were added to the weekly ward round paperwork. A statistical process control chart was used to monitor the rate of falls 6 months before and after the implementation of these changes to practice.

Results: these two strategies were implemented in June 2017. By July 2017, all patients had the date of their last fall recorded in their clinical notes. This was reviewed in March 2018 and adherence to this strategy remained 100%. Further, it had been expanded on spontaneous staff initiative to another ward. Falls continue to be discussed on weekly ward rounds. The statistical process control chart showed a reduction in the rate of falls from 3.80 to 1.76 per 100 occupied bed days.

Conclusion: changes to practice and improvements in care can be successfully implemented and sustained when frontline staff are empowered to make decisions based on routinely collected clinical data. The increased awareness of falls amongst staff and prompt multi-disciplinary reviews post falls may have contributed to a reduction in the rate of falls on the ward.

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More information

Published date: 9 October 2018
Venue - Dates: Wessex Safety, Quality & Improvement Conference 2018: Culture: How it impacts on Patient Safety and Quality Improvement, Novotel, Southampton, United Kingdom, 2018-10-08 - 2018-10-08

Identifiers

Local EPrints ID: 426514
URI: http://eprints.soton.ac.uk/id/eprint/426514
PURE UUID: 2c19e57b-ded8-41a6-8ae5-0678e8be70ad
ORCID for Ana Carolina, Vieira Goncalves: ORCID iD orcid.org/0000-0003-4055-0894

Catalogue record

Date deposited: 29 Nov 2018 17:30
Last modified: 21 Nov 2021 14:32

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Contributors

Author: Ana Carolina, Vieira Goncalves ORCID iD
Author: Sara Demain
Author: Alda Marques
Author: Dinesh Samuel
Author: S.A. Belward
Author: K. Legg
Author: R. Meredith
Author: L. Scaddan
Author: S. Howard
Author: T. Marshall
Author: D. Jeffery
Author: H. Wharam

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