Standards of Practice

A Quality Improvement Project Aimed at Reducing Patient Falls in Ambulatory Clinics

Patient falls are a preventative safety issue that needs to be addressed across healthcare settings. Patient falls increase patient hospital-acquired injuries, extend hospital stays and increase healthcare costs (Macolino et al., 2024). Ambulatory clinics are at higher risk for patient falls as their patients are often more mobile and less supervised (Macolino et al., 2024). The quality improvement (QI) project identified patient fall risks in ambulatory clinics and implemented targeted strategies to identify patients at risk for falls to increase the clinical team’s readiness for patient assistance.

Project Overview

Traditional improvement methodologies were utilized by the QI project to identify patient fall risk factors in ambulatory care. A root cause analysis and process mapping identified vulnerabilities in the subjective screening process for fall risks and aimed to improve communication with patients. Traditional data collection included a one-way text to patients prior to in-clinic screenings as a reminder to patients to wear comfortable shoes, bring their assistive device, and bring a support person if required. A follow-up message was sent after the visit with 2 custom questions to confirm patient education. The QI project reformulated an assessment question to “Do you use a cane, walker, wheelchair, or furniture to get around?” As well, created a new prompt to clinicians if patients answered “yes" to the question, “Have you fallen more than once in the past year or hurt yourself in a fall?” The new prompt simulated an FYI Falls Risk flag in the patient’s EMR to notify the clinical team of the assistance requirement for toileting, changing and transfers. The QI team’s screening question and EMR prompt increased the focus on fall prevention leading to a reduction from 0.050 in fiscal year (FY) 2022 to 0.039 in FY 2023, a 22% reduction. The fall rate for ambulatory patients continues to decline, the current annual falls rate for FY 2024 is 0.030 through February, a 37% reduction from FY 2021 rate 0.051.

Contribution to patient Safety

The project proved positive for patient safety by systematically addressing identifiable risk factors for preventable falls. The use of continuous patient monitoring and implementing evidence-based interventions enables ambulatory clinics to create a culture of safety. The fiscal reduction in patient falls demonstrates the effectiveness of the QI approach to patient safety.

Role of Nurses in Patient Safety

Nurse's frontline position in patient care positioned their role as an important component of the success of the project. Nurses were able to observe patient behaviors, identify potential facility hazards, and implement/evaluate preventative measures. The clinical experience of nurses contributed to the development of realistic strategies, and provided a collaborative components for the project to consult for unique insights on real-time feedback. Obtaining the compliance from nurses on the utilization of the prevention measures promotes long-term engagement to ensure adherence to safety protocols and can provide sound feed-back for adjustments that can be made quickly.

Integration of Best Practice Guidance

The QI project maintained the standards of the Registered Nurses Association of Ontario (RNAO) Best Practice Guidelines (BPGs) by restructuring pre-clinical assessment questions to determine patients at risk for falls thus, promoting their safety through supervisor and clinician knowledge opposed to traditional restraints. Adherence from clinicians, demonstrated in the reduction falls statistic, ensured the interventions met best practice standards (RNAO’s Provincial Election Platform, n.d.). The RNAO BPGs provides guidelines for QI projects to follow to ensure strategies are patient-centered and backed by scientific validity (RNAO’s Provincial Election Platform, n.d.).

Conclusion

The QI project showed that the implementation of targeted, evidence-based interventions can make systemic improvements in reducing patient falls in ambulatory clinics. Nurses played an important role in the success of the project by adhering to strategies and providing clinical experience and knowledge for meaningful improvements. The adherence to RNAO BPGs guidelines furthered the success of the QI project and maintained its validity.