swmc masks cropPictured are Southwest Medical Center’s (SWMC) staff who have been instrumental in assisting with its Focus on Falls initiative. Front row, left to right: Avery Ysac, CNA; Erin Guitron, CNA; Reyna Tarango, W/C; Courtney Chim, RN; Marian Eruagbere, RN; Jentry Strothman, LPN; and Beji Saji, RN. Back row left to right: Michael McCallion, LPN; William Salvador, LPN; Nichole Eatmon, CNA; Jaime Torres, CNA; Gissell Uribe, RN; and Mirella Buchman, RN, Nurse Manager.

Southwest Medical Center (SWMC) is a not-for-profit acute care hospital with 89 beds in Liberal, Kansas, also serving patients from nearby Colorado, Oklahoma, Texas, and New Mexico.

As part of their participation in the Compass HQIC program in partnership with KHC, SWMC identified falls prevention as one of its top patient safety goals. This is, in part, because the hospital saw a spike in patient falls during 2020 as compared to 2019. SWMC is now in their first five months of planning, educating staff, and taking action on interventions. They named the initiative “Focus on Falls.”

Jennifer Smith—BSN, RN, SWMC’s Director of Performance Improvement and Risk Management—said upon identifying falls prevention as its patient safety focus, leadership reviewed circumstances associated with patient falls in recent years. Much of that work was overseen by Mirella Buchman, RN, Nurse Manager.

“When we began looking at why our patients were falling, we identified a number of reasons," Buchman said. "One was equipment, and not knowing how to properly use it—for example, we had a couple patients trip over cords. We also had falls in the bathroom, from a patient reaching or just lost their balance. So started with a number of approaches to address these.”

Staff also considered whether the additional time required to don PPE before entering patients’ rooms could have contributed to the increased falls in 2020.

Among other things, the interventions SWMC implemented starting in March 2021 were:

  • More consistent employment of the “No Pass Zone”: Any time a patient alarm sounds, either a patient care or non-patient care staff member must investigate the alarm.
  • Education on equipment use and proper placement of cords.
  • Education on proper use of new beds.
  • Education on proper classification of patients at risk for falls.
  • Instituted default classification of patients as “high risk” for falls upon admission until a risk assessment is completed.
  • Patients with “moderate risk” and “high risk” for falls always assisted with restroom usage.
  • Installed yellow lights outside doors to indicate patients who are at “high risk” for falls.
  • Initiated safety huddles at the bedside twice per day, during which all patients at “high risk” for falls are reviewed.

Buchanan said staff members have responded well to the education and focus on falls prevention, particularly the many new staff members on their team.

“Everyone has been receptive to it. Our staff that have been here longer also appreciated it because having everyone together at the same time and getting the same education gets us all on the same page with expectations and working together,” Buchman said.

Sample resources from SWMC

Fall event tool for huddles (.pdf)

QAPI falls tool (.doc)

Post-fall huddle form (.doc)

Resources from Compass HQIC

Compass HQIC Metrics and Measurement Toolkit (.pdf, see page 46)

iCompass dashboard

So far, the results have been promising, although more work remains to be done. SWMC had 16 patient falls in 2020, and so far in 2021 they have had 9, closer to the total number they had in 2019 given their interventions began in March.

Buchanan said she thinks one of the most helpful interventions has been the huddles staff members conduct after each fall to review circumstances surrounding the fall and ways those should be addressed.

“Our post-falls huddles have gone particularly well,” she said. “For example, we had a couple falls where some staff didn’t realize that the patient didn’t have the alarm on. The huddle enabled everyone to talk it out—here’s what’s worked well and where did we miss something. I think the increased awareness and education is working and we’re starting to see encouraging results.”

Director Jennifer Smith agreed. "At first our focus was on the fourth floor due to an increased number of falls on that particular unit. Mirella Buchman had just taken on the Nurse Manager of that floor and was wanting to decrease the rate at the same time KHC rolled out their tools. The rest of the hospital is now learning from Mirella and moving forward with the same work that Mirella has outlined."

Smith said the increased number of falls likely was related to COVID-19. "The patients did not have significant others in the room with them and were more isolated," she said.

KHC Quality Improvement Advisor Heidi Courson said SWMC’s quick action starting right at the beginning of the HQIC project stands out for its thoroughness.

“SWMC has implemented nearly every intervention for falls prevention on the quality improvement work plan,” said Courson. “It says a lot about their quality department and leadership that they saw an issue and are taking proactive steps to address it. Their work to reduce falls will take time and persistence, but already it’s an example that others can follow.”