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708 posters, 8 topics, 16 sessions, 1,190 authors, 600 institutions

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ISQua's 39th International Conference 2023

August 27 - 30, 2023 | Seoul, Republic of Korea

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ISQUA2023-ABS-1542

SYSTEMIC ENHANCEMENT EFFORT TO ENHANCE FALL PREVENTION FOR PSYCHIATRIC INPATIENTS

Part of Topic

Patient Safety & Quality Improvement

Fall Prevention (FP) in an Inpatient Psychiatric Unit. Systematic Enhancement Effort to Address High Fall Rate.

Introduction

There was a raising trend of fall in Department of Psychiatry, TPH (32 in 2019 to 37 in 2020).

Prevalence of fall is higher in psychiatric inpatient settings than general settings due to psychopharmacological treatment and impaired cognitive function.

Fall could cause serious adverse physical and psychological outcomes (e.g. fractures, depressive symptoms). Based on the 4M1E principle (Man, Mechanism, Material, Method, Environment), a 2-year systemic fall prevention (FP) project was implemented since 2021 to tackle the raising trend of fall incidents.

Objective

Minimize fall incidents and related injuries.

Evaluation

Pre- and post- comparison of fall incident rate and fall-related fracture cases.

Actions Taken

Man

•2-day training workshops to nurses (FP knowledge, assisted walking skills
•Revised FP Training Program for fresh graduate nurses

Mechanism

•Enriched post-fall environmental visit and fall incident review
•Assigned fall representatives for each ward to support FP measures

Material

•Utilize FP Equipment
(e.g. Wireless Fall alarm mat, protective helmet, well fitted slippers)

Method

•Prompt/assist psychogeriatric patients proactively  for earlier toileting to tackle  toileting-associated fall

Environment

•Implemented routine environmental scan per shift to ensure FP measures are being applied

Results

The fall incident rate reduced from 0.33 in 2020 to 0.21 in 2021, and 0.18 in 2022.

There were 6 of 6 fall related fracture cases from 2020 to 2021, but no more fracture since OCT 2021.

Conclusions

•Fall incidents are multi-factorial accidents (Choi, et al., 2011)
•Systemic enhancement efforts are needed for sustainable improvement
•Cultural change and FP measures to be incorporated into daily practice are crucial
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