The Kaiser Permanente Tysons Ambulatory Surgery Center (ASC) Pre-Operative (Pre-Op) and Post-Acute Critical Unit Post (PACU) teams joined together to improve patient safety by creating an effective process to prevent and reduce patient falls in the ASC. By increasing effective communication, situational monitoring, mutual support, and leadership skills, the team successfully reduced patients’ fall incidents from two to zero by the end of the Q4 2017, all while working in a busy ASC with 7,842 operating (OR) cases in 2017. Their efforts have been recognized across the organization and earned them the Q1 2018 Josie King Hero Award.
The Pre-Op and PACU team’s project began with the formation of a Unit Based Team (UBT). The UBT was tasked with improving patient safety by increasing staff awareness in fall prevention. The team’s communication strategy focused on the use of closed loop communication, which helps to decrease poor communication and misunderstandings between team members and ensures a common understanding of patients’ needs. The closed loop communication process is used in the Pre-Op area to ensure the effective flow of the patient’s fall risk. The team also conducted a monthly staff meeting to review relevant information related to patient safety.
The team also uses the Schmidt Fall Risk Assessment Tool to identify patients with a fall risk. The tool helps determine a patient’s fall history, mobility status, mental orientation, and current medications regimen. The information collected was disseminated to other team members during the daily patient safety huddles.
Additional fall prevention measures included the implementation of high-risk patient identification with bright yellow wristbands labeled “Fall Risk”. A second intervention included the placement of a “Please Call Don’t Fall” sign located at the patient’s bay, and lastly, a call bell was placed within the patient’s reach. By implementing the fall risk assessment tool and interventions in conjunction with the team’s vigilance and closed loop communication technique, patient safety has improved in the ASC.
The fall risk assessment tool and closed loop communication techniques have proven so successful that they have been adopted in the Falls Church Medical Center Endoscopy department. Additionally, this project was submitted for the Accreditation Association for Ambulatory Health Care (AAAHC) survey and was accepted. The surveyors were very impressed.
Congratulations to the Tysons ASC team for achieving a high-quality outcome of reducing and preventing falls and for their well-deserved award!
