588 / Preventing accidental falls of patients-users-visitors

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Identification of risk and harm
Implementation of Patient Safety initiatives / Activities There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
Accidental falls in health care facilities are determined not only by the personal pathophysiological characteristics of the patient / user but also by the structural and / or organizational features.
The national and international literature highlights the need to implement strategies to limit the phenomenon in order to retain costs related to the increase of the day hospital and the lawsuits.Over the years of 2007-2008, the ASL Roma H has received 19 compensation requests caused by accidental falls occurred in the facilities. These claims have been assessed as the only determinable data regarding a certainly broader phenomenon. It was therefore decided to set up a detection of accidental falls system regarding patients, users and visitors in the facilities through the use of a specially designed form, intended to detect, quantify and analyze the phenomenon and then identify prevention strategies.
Description of the Patient Safety Practice
 
METHOD:In 2009, based upon lawsuits issued in 2007/2008, it was decided to activate a six-month survey concerning accidental falls that occurred in the ASL facility through a specially designed form. After the activation of a regional sentinel events detection system, it was decided to extend the detection of the accidental falls system making it permanent.
After 18 months of surveying, it has been possible to quantify the number and types of falls and then to proceed with the development of a project aimed at preventing and reducing these adverse events.
The project started from the data analysis which allowed us to identify the measures needed. Referents of the project for each facility have been identified and measures have been taken to raise awareness of the health workers in order to implement the organizational plan. A structural technology upgrade has been requested along with the activation of a health education program aimed at users.
Due to the nature of the specific risk (accidental falls), the project does not provide a deadline but ongoing monitoring to assess the effect of measures, the reduction of events and the possible planning of further actions.The project, started from the data analysis which allowed to identify the measures needed, has been planned according to the methodology HFMEA (Health Care Failure Mode and Effects Analysis), with an interdisciplinary analysis used to assess the processes considered more risky, the identification of potential vulnerability, the creation of the ASL (all the facilities) risk map and proposals aimed to decrease the risk of falls.
The method involves the following steps:
• Identification of the object of the analysis
• Identification of related activities
• Identification of procedure error/failure
• Priority of risk analysis and identification
• Identification of actions and measures to be taken
IMPLEMENTATION:
In early 2009, the Union of Risk Management has developed and proposed the project for the detection of accidental falls in the health sector. The project was approved by the Health Management Authority, and was started June 1, 2009 after being introduced to all the Macro-facility Directors and the Heads of the Nursing Offices. The project includes the following:
• Introduction of a falls detection form used in all cases of users falls (hospitalized or not) and visitors in the ASL Roma H facilities;
• Designation in each Macro-facility of two representative in charge of implementing the use of the form and reporting to the Union of Risk Management.
After the first three months of surveying it has been possible to produce an initial assessment of the data on which the hospital falls prevention plan was developed and distributed through the Hospital Macro-facility Representatives. The report about the data collected was filed at the end of the 6 months.
In March 2010 in the ASL Roma H, the regional project Rating ASL was activated for the 16 sentinel events identified by the Ministry of Health. Since the sentinel event no. 9 concerns "Death, coma or severe damage by the patient fall ", during the meetings for the presentation of the Project Rating ASL attended by the directors of macro-facility, the directors of UOC and the leaders of Nursing Office, it has been given the word, only for accidental falls of patients and users, to use the form prepared by the Union of Risk Management instead of the one from the project Rating ASL.
Thus, the collection of data relating to accidental falls has continued after the initial term of the project, becoming an established practice.
EVALUATION: 1.Objective: identification of patients at risk for falls and activation of a dedicated assistance program.
Indicator: Enabling internal operational protocol (choice of rating scales).
Expected result: activation after 1 year in at least 50% of the facilities.

2.Objective: guarantee of a obstacles free environment.
Indicator: activation of internal procedures for the disposal of furniture;
Implementation and registration of periodic controls.
Expected result: activation after 1 year in at least 50% of the facilities; 3/4 surveys / year in at least 50% of the facilities;

3. Objective: endorse to the ASL procedures of falls reporting.
Indicator: registration of meetings / focus groups conducted by representatives: falls report form relating to events for which compensatory damages could be asked for.
Expected results: at least 2 meetings / focus groups for each facility per year; possible check in the medium / long term.
4. Objective: inform and train the operators.
Indicators: registration of meetings / focus groups conducted by the representatives: training courses for the prevention of falls while performing care activities.
Expected results: at least 2 meetings / focus groups for each facility every year; training carried out for each new acquired assistance; formal training for new employees.


Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Yes
Specification of implementation in another health care setting(s)
Hospital
Successful implementation's level  of this Patient Safety Practice across settings
Yes, across multiple specialities across different health care settings
Involved health care staff
 
Physicians
Nurses
Health care assistants
Pharmacists
Technical support / technician
Clinical manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient(s)
Relative(s)
Other
Point of time in which service user or their reprasentatives' involvement takes place
During the development of the Patient Safety Practices
During implementation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
No
Short description of the service users' level of involvement
Consultation, such as asking for information
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/practicesdetail.aspx
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Regular data feed back to involved staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
Yes
Total number of person days required to implement this Patient Safety Practice
Clinical staff: 1
External consultants: 0
Support staff: 1
Managerial staff: 0
Others: 0
Not relevant: 0
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 1
External consultants: 0
Support staff: 1
Managerial staff: 0
Others: 0
Not relevant: 0
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
8812.45
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
0
Contact information
 
Name: SANTINA MEDAGLINI
Country: ITALY
Organisation: ASL ROME H
E-mail: s.medaglini@aslromah.it
Phone: 0039/ 0693277574 0039/0693273419
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