AHRQ Toolkit Helped Madonna Rehabilitation Hospital Reduce Patient Falls by 21 Percent

Patient Safety
July 2018

Patient falls resulting in injury were reduced by 21 percent at Madonna Rehabilitation Hospital after the Lincoln, NE, facility implemented AHRQ’s Preventing Falls in Hospitals Toolkit in 2015.

Madonna Rehabilitation Hospital, a 48-bed post-acute care facility, prevented eight patient falls during a nearly 2-year period, saving an estimated $107,000 in medical costs, according to Jackie Krason, R.N., M.S.N., the hospital’s quality and risk management supervisor.

AHRQ’s toolkit helps hospitals overcome the challenges associated with developing, implementing, and sustaining a fall prevention program. Fall prevention involves managing a patient's underlying fall risk factors and optimizing a hospital's physical design and environment.

Using the toolkit, the hospital updated its fall risk assessment system to use more specific risk factors, which enabled the registered nurses to better identify patients at greatest risk of a fall. Krason said this is where the AHRQ toolkit really made a difference.

“We developed and tested a new system that could accurately assess the impact that cognition, history of falls, gait, and balance had on a post-acute care patient’s risk of falling,” Krason said. “We previously had a falls prevention program in place, but it was definition-driven instead of risk-driven.”

The AHRQ toolkit also includes guidance on ways to build internal support for a fall prevention program, which Krason called “quite invaluable in establishing buy-in among our hospital’s leadership.” Staff education is also emphasized in the toolkit, which led the hospital to provide annual, mandatory training for all employees. The in-person training includes an online component with a followup test as well as hands-on competency and is tied to an employee’s annual performance evaluation.

Surveillance of the physical environment is also important, noted Terasa Farlin, R.N., the hospital’s nurse manager. “With our facility’s increased focus on preventing falls, nursing staff and therapists now conduct an assessment of the condition of each patient’s room during their hourly rounds. This presents the opportunity to relocate unneeded equipment or electrical cords that could pose a hazard.”

Given that a patient’s length of stay can range from 2 weeks to 4 months in the rehab facility, “we need to keep their living space as organized as possible to prevent a possible fall,” Farlin added.

Madonna Rehabilitation Hospital was one of several facilities recruited to participate in a project that evaluated the effectiveness of AHRQ’s Preventing Falls in Hospitals Toolkit. “We benefitted greatly from the project in helping us improve measures for fall prevention,” Krason said.

Impact Case Study Identifier: 
AHRQ Product(s): Preventing Falls in Hospitals Toolkit
Topics(s): Healthcare Costs, Quality of Care, Medical Errors, Outcomes, Patient Experience, Patient Safety
Geographic Location: Nebraska
Implementer: Madonna Rehabilitation Hospital
Date: 07/18/2018
Page last reviewed July 2018
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