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Illinois hospital huddles up to stop patient falls

Staff Development Weekly: Insight on Evidence-Based Practice in Education, June 23, 2006

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At Elmhurst (IL) Memorial Hospital, Education Coordinator Anne Stezowski, RN, and her staff have started using the post-fall huddle to help determine why a patient has fallen, and what can be done to help prevent such falls in the future.

When a patient falls, it should not be viewed as a failure by staff, Stezowski says. Instead, staff should see it as a learning opportunity. Hopefully, the lessons drawn from the fall can prevent more incidents in the future.

Once a patient falls at Elmhurst, where about 65-70% of inpatients are over the age of 65, staff notify a manager and Stezowski. A post-fall form is attached to the general incident form used by the facility. The fall form has specific questions staffers should ask the patient, the patient's roommate, and each other to help collect pertinent information, says Stezowski. The post-fall form is used in addition to the hospital's standardized general incident report, she says.

The fall incident form is then taken and reviewed in a post-fall huddle, in which the patient's nurse, the nurse manager, Stezowski, and as many other floor staff as possible review the information. They then discuss any changes that could have prevented a fall.

To get more tips that can help the quality of care that your organization provides, go to Briefings on Patient Safety (BOPS). For the cost of just three stories, you can get the entire June issue of BOPS. Click here to choose between the PDF and HTML versions for just $30. Subscribers to the online version of BOPS have free access to this article. Subscribers to the print newsletter can find this article in their June issue.

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