Improving compliance of applying fall

risk precautions for medium/high risk

patients for fall in in patient units

Improvement Project utilizing FOCUS PDCA

Methodology.

Find The Problem

• Based on the data provided by the clinical audit

department it was noted that only 33% of the

observed sample had completely all the fall risk

precautions applied.

• Which meant about 67% of the patient stated to be

at high risk for fall were at risk of fall because

incompliance to the proper fall prevention

precautions.

33%

67%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Complete Incomplete

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Compliance

Percentage of Compliance For Fall Risk Precautions.

EL-Iman Hospital; Dhulhaj 1434.

N= 115

Find The Problem

• Further data collection was made to determine which

of the fall risk precautions were more frequent to be

not applied.

30%

24%21%

16%

5%3%

0%0%

5%

10%

15%

20%

25%

30%

35%

F sign onDoor/Bed

Low bedPosition

ID Band Side Rails Avoidclutter

Dim Light LeaveDoorOpen

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Precautions

Percentage of Incompliance of Different Fall Prevention Precautions.

El-Iman Hospital; November 2013. N= 115

N(Incompliance)=77

Find The Problem

• The most common fall precautions (vital few) that

showed incompliance (80%) were:

• F Sign on door.

• Low bed position.

• ID band.

Organize The Team

• Team leader: Mrs. Hanan (Nursing deputy manager)

• Facilitator: Dr. Reem (Quality Manager)

• Members:

• Dr. M. Raslan (Deputy Medical Director).

• Mr. Abdullah (Biomedical dep.).

• Mrs. Janet (Nurse Supervisor).

• Mrs. Entesar (Nurse Educator).

FLOW CHART

Incompliance with fall risk

Precautions application

Equipment

Materials

People

Policy

Nurse Busy

Nurse Negligence

Unawareness of the

policy

Escort Interference

F sign not available

Bed Broken

Patient Incompliance

Unawareness of

Required Precautions

Nurse Can’t Use

Morse Scale

Broken Side Rails

ID bands Not Available

Understand The Variation

• A data collection sheet was made to verify the

frequency of the causes generated by the

brainstorming the team performed.

• And a sample size of 115 cases was determined to

detect the frequencies.

25%

20% 20%

11% 11%

5% 5% 5%

0%

5%

10%

15%

20%

25%

30%

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Causes

Percentage of Causes of Fall Risk Precautions Incompliance

Al-Iman Hospital; Muharam 1435.N=52

Vital Few Involved

1. Nurse is busy (Gives other care requirements

higher priority).

2. Escort Interference.

3. F Sign not Available.

4. Broken Bed.

5. Nurse unawareness of the policy.

59%

41%

Percentage of Beds Condition in Inpatient UnitsAl-Iman Hospital; 1434

Broken Beds

Functioning Beds

N= 207

100%

42%

88%

60%

27%

50%

65%

44% 46%

7%

0%

20%

40%

60%

80%

100%

120%

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Area

Percentage of Broken Beds In Inpatient UnitsAl-Iman Hospital; 2013

N= 207

Problem Action Responsible

Person

Due Date

Escort

Interference.

Nurse Education About

Importance of Patient &

Family Education About

Fall Risk and Precautions

Applied. (Every Monday

Nursing Lecture).

Ma’am Comfort

(Nurse Director).

Every

Monday Till

All Nurses

Are Covered.

Nurse

unawareness

of the policy.

Nurses Training &

Education.

Ma’am Comfort

(Nurse Director).

Every

Monday Till

All Nurses

Are Covered.

F Sign not

Available.

Replace The paper made

Signs with laminated F

Signs in all units.

Nursing

Department.

2/1435

Broken Bed. All beds which need spare

parts are to be provided

and fixed.

Biomedical Dep.

Nursing Dep.

3/1435

18%

82%

Percentage of Beds Condition in Inpatient UnitsAl-Iman Hospital; 1435

Broken Beds

Functioning Beds

N= 207

100%

42%

88%

60%

27%

50%

65%

44%

46%

14%

16%

33%

0%

0%

0%

65%

0%

50%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Male Surgical Ward

Male Medical Ward

Male Specialist Ward

Female Surgical Ward

Female Medical Ward

Gyn. Ward

L&D

Obstetric Ward

Paediatric Ward

Percentage

Are

aPercentage of Broken Beds In Inpatient Units

Al-Iman Hospital; 2013

After Before

33%

84%

23%

77%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12/1434 1/1435 2/1435 3/1435

Per

cen

tage

Month

Percentage of Compliance For Fall Risk Precautions.

EL-Iman Hospital; 12/1434 : 3/1435.

Invalid Data

Before Bed

Repair