Using the “Colors of Safety” to Decrease Patient Falls
Cathy Binck RN, MSN and Mary Walsh, RN, MSN, CEN
1
2
Beatrice Renfield Division of Nursing Education and Research and Patient Care Services , Beth Israel Medical Center, New York, NY
Standardization across sites of assessment, management and documentation of
fall risk allowed Continuum hospitals to benchmark both internally among sites
and against state-wide and national falls data. This safety and quality program
also integrated with the national safety efforts to create a “Colors of Safety” program. The Fall Prevention Program was then standardized using National “Colors
of Safety” designations.
The new fall prevention program includes:
•The use of the color yellow to visually identify at risk patients.
•Communication of risk status with all levels of
hospital staff through the use of the words “fall
SK
I
R
L
risk” prominently displayed on ID bands, door
FAL
signs and chart stickers.
•System-wide stratified fall risk assessment in the
electronic medical record.
•The development of a standard plan of care.
FALL
RISK!
One of the key components of the program provides at risk
patients with yellow treaded slipper socks.
Fall Risk Assessment Tool
Council on Nursing Quality Standards and Practice meets
Jan 2008
and agrees on goal of decreasing falls in hospitalized
patients.
Practice committee (PC) analyzes baseline QI fall incidence
Feb-March 2008
data and conducts literature review.
Practice committee makes recommendations to council for
unified fall prevention program. Chief Nursing Officers
March 2008
agree and present material requirements to Broadlane for
pricing.
Practice committee develops program criteria. Criteria
April 2008
submitted to Information Systems for creation of PRISM
screens.
PRISM implementation team creates assessment tool
April-May 2008
screens
Nursing Education develops education plan.
Council collaborates with Public Affairs to design hospital
and community publicity campaign. Campaign includes
May 2008
newsletters, posters, ID cards and media coverage. Council
members interviewed by CBS news and The New York
Times.
Nursing Education conducted.
June-July 2008
Fall Prevention Program implemented.
Continuum-wide education and publicity campaign for Fall
July-Oct 2008
Prevention and Colors of Safety programs.
July-Dec 2008
Data is collected for analysis and findings.
Specific performance improvement changed implemented
Jan-March 2009
Program analysis and evaluation.
PRISM Screens
Measurement, Data Analysis and Findings
As part of Continuum’s Quality Performance Measures, falls per 1000 patient
Falls in hospitalized patients, according to national data, are at a rate of 2.3 to 7.0 days as well as rates of patient falls with injury are calculated and reported on a
falls per 1000 patient days, which places the patient at risk for injury and increased monthly basis for all hospital sites.
length of stay. In 2004 it was reported that approximately 30% of inpatient falls re- The exemplar units at each site showed a decrease in rate of patient falls. For exsulted in injury, with up to 6% resulting in serious injury. Falls during hospitalization ample, data analysis showed a decrease in falls per 1000 patient days of 1.34 on
place a patient at risk for fractures, closed head injury, pain, permanent disability or 22 units at BIPD and of 0.155 on 6 units at BIKHD. At LICH although there was
even death. Through accurately assessing patients at risk for falls, identifying these no change in the fall rate in the 3rd and 4th quarters of 2007 compared to the same
patients at risk of falling with yellow ID bands, signs, and treaded slipper socks period in 2008, 4.23 (4.42), there was a significant decrease in the fall rate (3.14)
helps alert all hospital staff to the safety needs of this vulnerable population. Thus from the first quarter of 2008 to the first quarter of 2009 (0.95). At SLRHC, there
the inherent vigilance of this initiative contributes to increased patient safety.
was a decrease of 2.0 falls per 1000 patient days on 5 units from the 3rd and 4th
quarters of 2007. The same applies for the 3rd and 4th quarter in 2008. (See graphs
and tables)
Resources Allocated
Resources for program materials such as production of chart stickers were
budgeted. The ongoing financial impact of this program is the cost of the yellow
treaded slippers.
Standard Nursing Care Plan: Patient who is at Risk for Falling
Jul-Dec 2007
Jul-Dec 2008
3
2
1
2
1
0
8 Silver
7 Linsky
4 Bernstein
Petrie
KHD
SL
RH
0.0035
SLR
BI
LICH
NYS Benchmark
0.0025
0.002
0.0015
Jul-Dec 2007
Jul-Dec 2008
12
8
6
4
2
9E
Med Surg
Q2
Q3
Q4
Q1
2008
Q2
Q3
Q5
Q1
2009
Specific performance improvement changes that were
implemented as a result of this initiative
•Introduction of stratified fall risk (low, medium, high) categories.
•Implementation of revised standardized plan of care.
•For at risk patients, introduction of yellow ID bands, conversion to yellow
treaded slippers from foam slippers and production of program signs and
stickers.
•Ability to compare fall risk data among Continuum hospitals.
10
C5
Med Surg SL
Q1
2007
7 Silver
14
8B
Med Surg RH
9B
Med Surg
10B
Critical Care
4
Fall Index
LICH
Falls with Injury
0.00
CHP Fall Prevention Program: 5 Exemplar Units--St. Luke’s-Roosevelt Hospital Center
Team Members
Vice Presidents, Patient Care Services
Marie Flordeliza RN, MSN, BIMC
Catherine Gallogly RN, MSN, LICH
Susan Dietz RN, MSN, SLR
Sonja Tennaro RN PhD, NYEEI
Mary Walsh RN, MSN BIMC
Continuum Council of Quality Standards and Practice
Chairperson:Carmen Schmidt RN, MSN, Director of Nursing Education
and Research BIMC & SLRHC
Practice Committee Chairperson: Laura O’Brien RN, MSN, Clinical
Nurse Specialist BIMC
Practice Committee Members
Staff nurses: Pat Davitt RN, BIKHD, Ingrid Bonner RN, BIPD, Natalie Toney RN, LICH, Carmella Barone RN, LICH, Min Jeon RN, NYEEI,
Theodora Dee Morabe RN, NYEEI, Cho Young,RN, SLRHC, Silvia Monserrate RN, BIPD, Sarah Lopez-Rivera RN, BIPD, Theresa Mangalindan
RN, BIPD
Leadership: Betty Furr RN PhD, Director, Quality Standards and Practice, BIMC, Cathy Leota, NM, BIKHD, Lydia DeGracia DN, NYEEI, A.
Alvaredo DN, NYEEI, Rosa Williams DN, SLRHC, Michelle Dunn QI, SLRHC, Grace Phelan, Sr. Nurse Education Manager, SLRHC, Thelma
Myers-Navarro DN, PACC, Charles Tilley NM, BIPD, Elizabeth Metz NM, BIPD
3
2
1
0
3
0.0005
5
In addition, at each hospital, comparing the 3rd and 4th quarters of 2007 to the
same period in 2008, exemplar units showed a decrease in fall rate following the
program implementation.
4
0.001
CHP Fall Prevention Program: LICH Implemented July ‘08
Following implementation of the fall prevention program, there was a decrease
in patient falls with injury in the 3rd and 4th quarters of 2008 in three of the four
hospital sites.
5
0.003
4
0
Jul-Dec 2007
Jul-Dec 2008
6
5
0
The quality or patient safety achievement
7
CHP Fall Prevention Program: 4 Exemplar Units-Petrie
Through the Continuum Council for Nursing Standards Practice and Research,
nursing leadership and staff nurses from all Continuum sites contributed time in
kind throughout the planning, education and implementation process. Other corporate departments also provided time and financial resources in support of this
program.
Public Affairs and Marketing assisted in the system-wide publicity and education
initiative through: internal (posters, newsletters, staff ID card reminders) and local
and national media (NY Times, CBS TV and Radio, Advance for Nurses). Information Technology contributed in kind time to develop the new assessment flow
sheet in PRISM. Organization, Development, Education and Talent Management
provided time in kind to create the Spotlight On newsletter distributed to all Continuum employees.
CHP Fall Prevention Program: Launched July ‘08
Fall Index
Although the incident of patient falls in Continuum hospitals are below the New
York State benchmark, in 2008 the Nursing Departments across Continuum agreed
upon a goal for decreasing the incidence of falls in hospitalized patients. In response, the Continuum Council for Nursing Standards Practice and Research,
looked at evidence-based nursing practice issues across all hospital sites, and developed an innovative system-wide fall prevention and documentation program.
Why is this initiative important and its specific impact on quality
and patient safety
Fall Index
Key Activities and Timeline
Fall Index (# falls/1000 pt days)
Continuum Nursing Fall Prevention Program
2
Fall Index (# falls/1000 pt days)
1
Jul-Dec 07
Jan-Mar 08
Jul-Dec 08
Jan-Mar 09
Quality committee chairperson: Donna Wilson RN, Director of
Performance Improvement
Nursing Education
Cathy Binck RN, MSN Senior Nurse Education Manager, BIMC
Grace Conte RN, MA, Nurse Education Manager, KHD
Grace Phelan RN, MA, Senior Nurse Education Manager, SLRHC
Maureen Rieb RN, MSN, PRISM Coordinator KHD
Information Systems
Laurie Buckenberger RN, NP, Clinical Director IS
Organization Development, Education and Talent Management
David Kraft, Corporate Director; Karen Barrowclough, RN, Director
Continuum Public Affairs and Marketing
Elizabeth Dowling; Don Maxton; Jim Mandler