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Operational Excellence, Psychiatry


Patients falling as a result of geriatric and psychiatric impairments are at a much higher risk than the average patient population. An acute care inpatient psychiatric team used baseline metrics to demonstrate increasing fall rates per month that surpassed the unit’s target number. As a result, a quality improvement project around falls was felt to be warranted.

The overall goal of this study was to improve patient safety by reducing falls for their very high risk fall population. A root cause analysis determined that this population was not being properly identified and several tools were developed and employed to better assess and visually identify this group of patients.

Post KPI implementation, the unit reported a 95% reduction in falls of those patients deemed very high fall risk. Next steps involve hard wiring the countermeasures to obtain outcome sustainment.



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