presented by Pat Quigley
All organizations strive for falls to be “never events” in healthcare. However, falls remain among the top adverse events patients experience in hospitals and nursing homes. When a fall occurs, interventions must be implemented to decrease the chance of reoccurrence. During this course, rehabilitation nurses will: discuss the role of a post-fall huddle as a group consensus approach to determine the immediate/root cause of the fall; differentiate the post-fall huddle from other post-fall management components (incident reports and medical record documentation); and illustrate a post-fall huddle program evaluation model.
Dr. Patricia Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP, Nurse Consultant, is a retired Associate Director of the VISN 8 Patient Safety Research Center of Inquiry and is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation. Her contributions to patient safety, nursing, and rehabilitation are evident at a national level, with emphasis on clinical practice innovations designed to promote elders’ independence and safety. For over 40 years, Dr. Quigley has practiced in the field of rehabilitation nursing, including 32.5 years with the Veterans Administration. She serves as patient safety expert for fall and injury reduction to the American Hospital Association, Washington State Hospital Association, Alaska State Hospital and Nursing Home Association, and their Hospital Engagement Networks – now Hospital Improvement Innovation Networks. She also served as fall and fall injury prevention subject matter expert for the 2013 AHRQ National Falls Toolkit and the 2008 and 2013 Institute for Healthcare Improvement Reducing Serious Injurious Falls on Medical Surgical Units. Dr. Quigley serves as a committee member of the NQF Patient Safety Standing Committee and past member of the NQF Patient Safety Complications Steering Committee, nominated by ANA. Her leadership resulted in redesign measurement of patient safety indicators for falls and fall injuries that link organizational, unit, and patient-level variables that are relevant and evidence-based. With a legacy as primary and co-investigator on health services and rehabilitation research, she has conducted large-scale studies to examine trends and cost savings on national interventions to reduce harm from falls. Dr. Quigley has served as principal or co-investigator in 35 research studies, totaling over $7.5 million. She has a track record of interdisciplinary research with health economists, epidemiologists, and statisticians for population-based outcomes research. Dr. Quigley has co-authored and served as associate director for eleven VISN 8 Patient Safety Center of Inquiry center grants from 1999-2016, totaling over $13 million. She has authored or co-authored more than 60 peer-reviewed manuscripts and more than 50 non-peer-reviewed manuscripts, book chapters, products, and media works. Dr. Quigley is grounded in practice, with a legacy of leadership in healthcare outcomes related to functional improvement, rehabilitation outcomes, and continuum of care. For over 20 years, she led an interdisciplinary clinical team in the development of evidence-based assessment tools and clinical guidelines related to assessing veterans’ risk for falls and fall-related injuries across multiple medical centers. Additionally, she provides ongoing consultation to the nursing staff, quality management, and patient safety coordinators for management of complex patients at risk for falls.
When a patient fall occurs, staff members make every effort to immediately respond. They assess the patient’s status upon rescue, uncover the circumstances of the fall, and then decide on appropriate care management. A group of providers struggle to ascertain the immediate or root cause of the fall. Acknowledging that 80% to 90% of falls that happen in hospitals are unwitnessed (Oliver, et al., 2010), patient involvement in the post-fall huddle is essential. This chapter dramatizes the conduct of an actual post fall huddle following a patient fall.
A fall event generates an organizational response to investigate and understand all the contributing circumstances of the fall. This organizational response is observable through various communication systems: huddles, post-fall assessment, incident reports, and hand-off communication. In this chapter, rehabilitation nurses will distinguish the value of each component of post-fall management and the unique purpose of the post-fall huddle as the first action from all other huddles, outline the eight steps of the post-fall huddle process, utilize accident theory to visualize the complexity of immediate/root cause determination.
Program evaluation is a detailed and comprehensive process that includes formative and summative components. Fall rates, as an outcome, are insufficient to examine the effectiveness of fall prevention. Rather, the post-fall huddle should be examined as a program intervention that, when implemented provides increased depth and breadth to understanding patient falls. During this chapter, rehabilitation nurses will learn a detailed program evaluation model applied to post-fall huddle to determine efficiency and effectiveness.