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Dome - A team approach to preventing falls

March 2012

A team approach to preventing falls

Date: March 5, 2012


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Patient falls are a common occurrence in hospitals, according to numerous national studies. Falls rate can range from more than 2 to more than 9 falls per 1000 patient days, with 30 percent of them resulting in serious injury to patients. They’re also costly—prolonging hospital stays, depleting resources and leading to malpractice suits.

And, they’re widely considered by patient safety experts to be preventable.

To both decrease the number of incidents and to better understand why patients fall, Suburban Hospital’s nursing staff has employed a new multidisciplinary fall-prevention initiative called the Morse Team. The name comes from the Morse Fall Scale, a method of assessing a patient’s likelihood of falling.

Available at all times, the Morse team comprises a registered nurse, a patient care tech, a pharmacist and a nursing supervisor, who immediately gather at the site of the fall. As soon as the patient is stabilized and returned to a safe place, the group investigates the cause of the incident. They evaluate the physical environment, the medications that the patient has taken and the patient’s ability to understand instructions. The team generates a report, which is reviewed by the hospital’s nursing quality safety service council.

“This is a nurse-driven initiative that provides us with real-time understanding and education,” says nurse Carolee Beckford, the council’s chair. “We reviewed the falls data and identified the need for a change. Nursing council members researched best practices, created and approved the practice change, and educated the entire organization.”

Since the Morse Team was created in November 2011, the incidence of falls at Suburban Hospital has remained under the Joint Commission’s benchmark of 3.73 falls per 1000 patient days. Patients, family members and visitors have taken notice of the process and have voiced their satisfaction. They like knowing that Suburban is focused on preventing falls. “It’s a hospital-wide initiative owned by everyone,” Beckford notes.

—Debra Scheinberg

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