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The Safety Huddle: Preventing repeat falls and near miss falls

Project Added:
23 October 2015
Last updated:
9 November 2015

The Safety Huddle: Preventing repeat falls and near miss falls

Summary

Camden Hospital implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.

Safety Huddle in action - the team with a patient
Safety Huddle in Action (L to R): Occupational Therapist Sara Millen, Nursing Unit Manager Brian Lane, Patient Mr Coutinho, Physiotherapist Jonathan Lee and Rehabilitation Registrar Dr Natalia.

Aim

To reduce the rate of repeat inpatient falls and near miss falls in the rehabilitation unit at Camden Hospital.

Benefits

  • Provides a structured, personalised intervention to reduce the risk of a repeat fall.
  • Improves staff compliance with safety protocols.
  • Develops a culture of patient safety that treats falls and near miss falls very seriously.
  • Provides a comfortable way for staff to offer an apology to the patient.
  • Increases situational awareness, so staff can anticipate situations that may lead to a fall.

Project status

Key dates

  • Start: October 2013
  • Finish: June 2015

Status

Sustained - The project has been implemented and is sustained in standard business.

Background

Inpatient falls are one of the most common patient safety incidents reported in rehabilitation wards and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death.

In 2013, two patients fell three times at Camden Hospital and in 2012, three patients fell twice. To reduce the incidence of repeat falls, the Falls Working Party at South Western Sydney Local Health District suggested a Safety Huddle as a multidisciplinary approach that involved the patient in falls prevention.

Implementation

The Safety Huddle consists of a multidisciplinary review of a fall or near miss fall, led by a nursing unit manager ( NUM ) and held in consultation with the patient. After determining the need for emergency care and acting accordingly, the post-fall Safety Huddle is convened as soon as practically possible. The process is as follows:

  • the NUM prepares the patient by explaining the purpose of the Safety Huddle and lets them know that the team will be arriving to see the patient
  • the NUM assumes the role of Safety Huddle team leader
  • the multidisciplinary team involved in the Safety Huddle may include nursing and allied health staff, a medical officer, the patient and their carer
  • staff apologise for the fall or near miss fall and explain how the team will work with the patient to prevent a reoccurrence, using strategies developed in collaboration with the patient
  • the team complete an analysis of the fall event and interventions for preventing a repeat fall are decided by the Safety Huddle team and patient
  • interventions are documented in the clinical record and on electronic nursing handover forms, with a sticker to indicate that a Safety Huddle was held
  • after the Safety Huddle, the NUM follows up with staff and the patient to ensure interventions have been implemented and answers any questions or concerns voiced by the patient or carer.

Involving the patient and where possible their carer is critical to the success of the Safety Huddle. It enables the patient to have a greater understanding of the strategies chosen to prevent a repeat fall and increases their adherence to these strategies.

An educational DVD is currently being developed to help other clinicians implement the Safety Huddle. Ethics approval is underway to evaluate patient and staff satisfaction with the project. The Centre for Applied Nursing Research is assisting with this process.

Implementation site

  • Camden Rehabilitation Unit, Camden Hospital

Results

  • Between October 2013 and June 2015, no patients had a repeat fall.
  • Fall rates per occupied bed days decreased by 40% from a mean rate of 4.2 to 2.5 falls per 1000 occupied bed days.
  • The Safety Huddle has generated a culture of patient safety at Camden Hospital and developed situational awareness, where staff are often anticipating situations that may lead to a fall.
  • The Safety Huddle has now been successfully translated to other areas of patient safety, including skin tears and medication incidents. Senior registered nurses and allied health professionals are now able to lead Safety Huddles in their department.
  • Findings from the Safety Huddle project have been presented at the Australian and New Zealand Falls Conference in November 2014, the NSW Falls Conference in May 2015 and the International Quality and Safety in Healthcare Conference London in April 2015.
  • Numerous facilities have shown interest in the Safety Huddle and information has been shared to assist these facilities with implementation.
  • Enthusiasm and commitment are vital to the success of the Safety Huddle, with buy-in required from allied health and medical staff for optimum results.
  • Providing the patient with an opportunity to discuss the fall from their point of view is important, as is their involvement in developing preventative measures to avoid repeat falls.


Graph 1: Pre-huddle mean falls of 4.2 falls per 1000 occupied bed days.
Graph 1: Pre-huddle mean falls of 4.2 falls per 1000 occupied bed days.


Graph 2: Post-huddle shows a decrease to 2.5 falls per occupied bed day, a reduction in falls per occupied bed days of 40%.
Graph 2: Post-huddle shows a decrease to 2.5 falls per occupied bed day, a reduction in falls per occupied bed days of 40%.

Awards

  • South Western Sydney Local Health District Quality Awards, Finalist, 2015 – Quality Improvement

Contacts

Brian Lane
Nursing Unit Manager
Camden Rehabilitation Unit, Camden Hospital
South Western Sydney Local Health District
Phone: 02 4654 6337 or 0438 371 516
Brian.lane@sswahs.nsw.gov.au

Bronwyn Everett
Associate Professor and Deputy Director
Centre for Applied Nursing Research, Western Sydney University
Phone: 02 8738 9360
bronwyn.everett@sswahs.nsw.gov.au

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