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Caught Ya & Engaging Front Line Staff in Fall Prevention

Susan K. Steele-Moses, DNS, APRN-CNS, AOCN; Academic Research Director
Sarah Pollard, Certified Nursing Assistant

All patients at some point during their hospital admission are at risk for falling.  In 2009 The Joint Commission’s National Patient Safety goals identified reducing the risk of patient harm as a priority. 

According to the Centers for Medicare and Medicaid a patient fall can be prevented, thus in 2010 Medicare stopped paying hospitals when a fall happened.  To successfully manage this challenge, one Medical Center in Southeastern Louisiana developed a Fall Team to look at best practice and decide if there were any changes needed in our fall prevention protocol.
We knew that it was important to engage front line staff including our certified nursing assistants. Sarah Pollard, CNA was the nurse assistant representative on the team.   Sarah has been a Certified Nurse Assistant for over 30 years and works with nurses who have been out school from a few months to a few years. Sarah is an advocate for her patients and reminds many of the younger nurses that it is important to keep their patients safe. She reminds the staff that every patient is a mother, father, sister, or brother and we should watch out for them like they are one of our own.  Working with the nurses on her unit, the staff came up with the idea to track the number of fall free days to celebrate their success.  If a fall happened, the number of fall free days was erased and reset to zero.  Then the staff would discuss the fall, identify what they could have done as a team to prevent it, and commit again to work together to keep their patient’s safe.  Sarah proudly led these discussions and the nurses listened and respected her leadership.  Over time Sarah’s unit successfully decreased their fall rate and increased there fall free days to over 100.  To keep the energy going on other units too, the Rapid Cycle Falls Team developed the “Caught-Ya” award to recognize staff who prevented patients from falling too.  Over time, Transporters, therapists, nurses and other CNAs were recognized.  Some of our CNA’s stories are below:

Ms. Price, CNA saw a patient across the hall trying to get out of bed alone. She stopped what she was doing and ran across the hall to catch him just in time. It is easy to say that’s not my patient.  But, when we are called to provide care for those who need us, no matter what our assignment, they all belong to us. Her quick thinking is an example of good fall prevention

Ms. Samuel, CNA was working on a unit during the night shift, and as she preceded to do my hourly rounds one of my nonverbal patients who is visually and hearing impaired was trying to locate a family member that was in the room. The family member was asleep and did not hear them. The patient was on the edge of the bed and was on the verge of falling to the floor. Ms. Samuel caught him and was able to put him back in bed before he fell. She rubbed his shoulders and reassured him in soothing tones that he was ok. Ms. Samuel also alerted the family member that was in the room, and they were able to reassure the patient that he was not alone. To keep her patient’s safe, Ms. Samuel made sure she did rounds on them frequently so that no future incidents could occur.