1. Road Map to Reducing Patient Falls
using an Integrative Approach
Date: October 18th, 2013
Submission: Virtual Poster Presentation at the Canadian Patient Safety Institute (CPSI)’s
Virtual Forum, Canadian Patient Safety Week 2013
Lead Author: Ivan Ip, Director, Quality, Risk & Safety/Chief Privacy Officer
Contributors:
Leo Chow, Patient Care Coordinator
Josh Moralejo, Nursing Practice Leader
Barbara McKenzie, Staff Physiotherapist
Emily Ho, Staff Occupational Therapist

2. Issue, Intervention and Measurement
What is the Issue?
•
Between 42 and 48% of reported incidents are related to patient falls.
How did we identify it?
•
Reviewing Quality/Risk Indicators from RAI Assessment, Patient Bedside Mobility Assessment, and Incidents Analysis
What is our Goal?
•
To reduce patient falls by integrating evidence-based falls guidelines into our interprofessional practice.
What are the Interventions?
•
•
•
•
Patient Falls Prevention Policy and education
Modified bedside patient mobility tool for identifying level of falls risk
Patient/family information pamphlet to raise falls awareness
Least Physical Restraint Policy and education
Measurement:
•
Monthly reported number of patient falls incidents, number of patient days, moving range, ratios of number of falls and
number of patient days; and the number and frequency of patients with 2 or more falls were measured and analyzed using
(a) u Control Charts for screening and (b) Individual and Moving Range (mR = 2) Control Charts at two and three standard
deviations to examine variation, pattern and extreme points.
Baseline Data:
•
•
Facility-wide and Unit-based data between Jan 2011 – Sep 2013 (variable data: Month, Number of patient days and
number of reported patient falls).
Number and Frequency of patients with 2 or more falls by Unit between Jan 2011 – Sep 2013

3. Contribution of the Initiative and
Lessons Learned
Contribution to Patient Safety and Quality Improvement—A Roadmap—2012 – 2014:
•
•
•
•
•
•
Increase staff competency in identifying patient at risk of falls
Identify opportunities of mitigating these risks by linking related initiatives and relevant information using an integrative
thinking and evidence-informed team-based approach.
RAI Assessment training provides an underpinning of the knowledge and skills.
Goldcare system offers an e-documentation platform timely interprofessional communication
Quarterly measurements against the baseline and realistic targets and institute appropriate course correction for
sustainable quality improvement effective Q3 of F2013/14.
Expected progressive change/improvement in 2014:
–
–
Reduced patient falls and both the number and frequency of falls amongst patients with 2 or more falls
Improved compliance rate in the appropriate use of physical restraints; and enhanced quality and utilization of Falls Avoidance
care plan for patients identified as at higher risk of falls.
Lessons Learned:
•
•
Team goal development was transitioned to reflect unique population-based quality improvement targets and a realistic
time line which shows important milestones on when targets will be met
Visual process mapping provide the power of integration; and serves as an effective tool for capturing business process,
integrating knowledge and people into effective teams through sound communication; and managing complexity of the
processes.

4. Road Map to Reducing Patient Falls
using an Integrative Approach
Collaboration
Debate
Communication, Team and Capacity
Building
Visual Process mapping facilitates
the collaborated team to:
• Review the Data and
Analyze
Strategize
tRAIn
Evaluate
Decide
Measurements
• Learn and understand the meaning
of the data and measured results
• Know what to do about it
• Know how to change it
• Believe it and own it
• Enable coordinated and coherent
Action to drive sustainable change
and the integration of best practice
Process Mapping
Best Practice Integration
RAI training for all clinical staff to promote
sustainable change and quality improvement
Predict
Patient
Falls Issue
Filtering
Patient Falls Issue to
develop a strategy for
an integrated and
coordinated
approach
Measure
Mapping
Strategy for
Prevention
and Falls
Reduction
Model
Developed a Falls Prevention Policy and
Online Education Program
Implemented a bedside mobility tool for risk
identification
Developed a least physical restraint education
program to reflect new guidelines from the
Least Restraint Policy
Achieve
progressive
reduction in
patient falls
and falls
related injury
in 2014