The National Patient Safety Foundation (NPSF), in conjunction with the National Association of Public Hospitals and Health Systems (NAPH), has awarded the 2011 Patient Safety Initiative at America’s Public Hospitals Leadership Award to Harborview Medical Center.
The honor was conferred on the Seattle, WA-based hospital during NPSF’s 2011 Patient Safety Congress for its notable actions addressing fall prevention and reduction.
“Falls threaten patients’ lives, safety and independence,” said NPSF president Diane C. Pinakiewicz, MBA. “They also have an enormous impact on the cost of health care. Harborview’s singular effort to reduce this preventable risk is a valuable public service and fully worthy of distinction.”
The Patient Safety Initiative is a collaboration of NPSF and NAPH. Launched in October 2009 with support of the Kaiser Permanente Community Benefit Fund, the program provides education, resources, and communication strategies that promote safer healthcare.
The award is given to a participating member in recognition of the successful implementation of an outstanding patient safety program and/or project that was created, executed, or advanced as part of their membership.
“NAPH is honored to recognize Harborview Medical Center for their leadership in advancing patient safety, and specifically, their commitment to eliminating patient falls,” said Linda Cummings, PhD, vice president for research/director of the National Public Health and Hospital Institute (NPHHI).
The Harborview Program
Harborview carried out a six month pilot program, which is now being rolled out hospital wide. The program endeavored to:
- Build the belief among staff that injuries from falls can be eliminated;
- Incorporate fall assessment discussion in daily rounds;
- Employ a fall prevention bundle for patients at risk for falls;
- Review medications for fall risk and adjust as indicated;
- Post fall data monthly on all care units;
- Consistently use a valid fall risk assessment tool and track compliance;
- Regularly communicate individualized information about patients at risk for injury from falls to all caregivers and hospital staff;
- Prevent falls and injuries with tools such as low beds with side rails, bed and chair alarms, one-to-one observation, non-skid slippers with treads on top and bottom, floor mats, and nurses walking patients with gait belts;
- Engage the entire hospital using data displays on units, discussion at organizational meetings, awareness education, and safety fairs;
- Engage both ancillary and medical staff in the process of fall and injury prevention, including hand offs between departments and assisting with identifying at-risk patients;
- Incorporate more celebration into the process by recognizing units for days between falls and reducing falls and related injuries.
At the end of the pilot phase, the number of falls decreased by nearly 40% on the trial unit and 23% hospital wide. This reduction was sustained over a seven month period. In this time frame, the pilot unit did not experience one fall that resulted in major harm, and the whole institution had two falls resulting in serious injury. The number of repeat fallers decreased by 38%, and that figure has continued to improve.