Excellence Every Day

EXCELLENCE EVERY DAY PORTAL

Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations.

A focus on falls — the leading cause of injury deaths among older adults.

			AN MGH NARRATIVE "Mrs. C was a 93 year old female admitted with a urinary tract infection (UTI). She had advanced dementia, ambulated with a walker, and was at high risk for falls. A nursing assessment, teamwork on the unit, and several patient-centered interventions successfully prevented a fall during Mrs. C's hospitalization." read more...

THE DATA

IMPROVEMENT INITIATIVES

FYIs

MGH Fall Rates
(falls/1000 patient days)
TREND: improvement needed
CLICK HERE for additional data

Oct.-Dec. 2011
Adult	MGH	NDNQI
Critical Care	1.18	0.99
Surgical	1.61	2.54
Medical	3.81	3.74
Med-Surg	3.53	3.42

Jul-Sept 11
Adult	MGH	NDNQI
Critical Care	0.89	0.99
Surgical	2.32	2.57
Medical	3.19	3.72
Med-Surg	5.96	3.40

NDNQI Benchmark:
hospitals with 500+ beds
Green = Favorable
Red = Unfavorable

IN THE NEWS
Watching their steps In an unusual new study, Boston-area seniors track their falls to help researchers find ways to keep them from happening -The Boston Globe, July 4, 2011

Let's Eliminate All Falls (LEAF™)
Led by Deborah D’Avolio, RN, PhD, LEAF™ is a comprehensive, evidence-based, fall-prevention program that has been rolled out on all inpatient units. The program uses a universal
train-the-trainer approach to educate staff on all aspects of fall-prevention, with special considerations for older and other at-risk patient populations. More about fall reduction...

MGH LEAF™ Toolkit:
(internal access only) For more information, please contact Deborah D’Avolio, RN, PhD .

Core Components of LEAF
Post-fall Debrief
Post-fall Guidelines
LEAF Case Study
Resource Nurse Handoff
LEAF Signage for Patient Rooms

HealthStream Offerings:
(internal access only)
MGH LEAF Fall Prevention Program
MGH GRAF PIF Scale, Pediatric
LTC Preventing Patient Falls

More Fall Reduction Resources
Collaborative Governance Falls Champions
Hourly Safety Rounds Tool Kit
Falls Q & A, Caring Headlines
Sensory Impairment, Caring Headlines
Falls narratives
MGH 65plus
In the literature

Policies, Procedures & Guidelines:
Fall Risk Assessment Standard for The Adult General In Patient Care Units
(internal access only)

IN TROVE, SEARCH:
"patient at risk to fall"
(internal access only)

Practice & Quality Subcommittee:
Fall Prevention -
meets the 3rd Thursday monthly from 1:00-3:00pm in Yawkey 7-980

Inter-Disciplinary Team
presents poster
Diane Carroll, RN; Ann Hurley, RN; John Dykes; and Blackford Middleton, MD, presented their poster, “Validation of Icons to Communicate Fall Risk and Tailored Interventions to Prevent Patient Falls,” at the 22nd Annual Scientific Sessions, Celebrating Diversity in Nursing Science, in Providence, March 25, 2010.

PATIENT EDUCATION

Preventing Falls in the Hospital and at Home - an MGH brochure
(Can be ordered through Standard Register, item #84167)

Fall prevention videos for patients: (viewable via MGH in-house TV) Dial 4-5212 on the bedside phone. Follow the voice prompts and enter video number into the system. Tune the television to the channel as instructed. The video will start playing within 30 seconds.

Fall Prevention (#104)

What hospitals do to prevent falls
Causes of dizziness
Hospital safety features
Non-cluttered environmentWhat patients can do
Techniques for safety at home

Fall Prevention (#211)

Patient scenarios of how falls happened
Recommendations to prevent them using the same scenarios
Higher risks for falls

SPOTLIGHT ON PRACTICE

"On our unit we have a prescribed pre-admission teaching plan for patients who are coming to the unit for Bone Marrow Transplant. Since the beginning of LEAF, we have added fall prevention to our teaching. We let our patients know that simply by coming into the hospital and receiving high doses of chemotherapy and transplant, they are at increased risk for falls. We have an RN unit quality group that evaluates our falls. Our RNs strive to teach about fall prevention on admission and on an ongoing basis throughout the patient's hospitalization."

Judith V. Curran RN, MS, AOCNS
Oncology Clinical Nurse Specialist, MGH Cancer Center, Ellison 14


EXTERNAL REVIEWERS
	The Joint Commission standard for prevention of falls includes the assessment of patients for risk, the education and training of patients and staff, and the collection of data on the effectiveness of falls reduction activities.			Magnet Recognition The American Nurses Credentialing Center (ANCC) requires Magnet-designated organizations to track nationally-benchmarked nursing sensitive indicators (NSIs) to continually inform improvement efforts related enhance patient outcomes. Examples of NSIs include, but are not limited to: patient falls, hospital-acquired pressure ulcers, blood stream infections, ventilator-associated pneumonia, and restraint use.

GLOSSARY OF TERMS

click here...

There are numerous terms and acronyms in healthcare that may be unfamiliar. Please click here to visit a Glossary of Terms that may be helpful. And please email any suggested additions.

This month's featured term: NDNQI
The National Database of Nursing Quality Indicators (NDNQI) is a proprietary database of the American Nurses Association (ANA). The database collects and evaluates unit-specific data from hospitals in the United States. Participating hospitals receive unit-based comparative data reports to use for quality improvement purposes.


Excellence Every Day represents an MGH commitment to providing the highest quality, safest care that meets or exceeds all standards set by the hospital and external organizations.

If you have questions or suggestions related to the EED portal, please contact Georgia Peirce at (617) 724-9865 or via email at gwpeirce@partners.org.

updated 4/5/12

Massachusetts General Hospital 55 Fruit Street, Boston MA 02114 / (617) 726-2000 / TDD: 617-724-8800