Post-fall huddles and reviews are standard care practices implemented by many healthcare organizations to systematically evaluate fall events among patients. The goal of these processes is to identify factors that may have contributed to a fall, mitigate future risks, and prevent repeat falls. After a patient experiences a fall, a multidisciplinary team typically conducts a prompt huddle at the bedside while details are still fresh. They then conduct a more formal review within 1-2 days to analyze findings in depth.

At my facility, we have worked hard over the past year to strengthen our focus on falls prevention as rates had been slowly creeping up. As part of our quality improvement efforts, we began mandating post-fall huddles immediately after any fall and follow-up reviews within 24 hours led by our falls committee. This allowed us to gather a wealth of insightful findings that are helping us better understand falls risks and implement targeted safety interventions.

Some of the most frequently identified contributors to falls uncovered through our huddle and review processes included: a lack of call light usage by patients, gaps in communication of fall risks on shift change handoffs, noncompliance with fall prevention interventions like alarm activation and hip protectors, missed rounds by nursing staff, and an insufficient number of staff to provide needed assistance in a timely manner. Environmental factors like uneven flooring, lack of secure handrails, and poor lighting were also flagged in certain areas as physical plant issues meriting examination.

We also found that patients presenting with certain medical conditions or recently prescribed new medications appear to be at heightened risk and warrant especially close monitoring. Conditions like delirium, confusion, new weakness, and gait instability emerged as common themes among those who sustained injurious falls. New medications that may cause dizziness, drowsiness, or impair balance seemed to interact as risk multipliers as well. Comorbidities like arthritis, impaired vision, and history of prior falls further compounded these risks.

Through analyzing fall circumstances in detail, some falls could likely have been prevented with more astute screening of intrinsic and extrinsic risk factors during admission assessments. Our reviews highlighted opportunities to bolster comprehensive geriatric assessments and apply standardized screening tools to systematically identify individuals’ personal fall histories, mobility limitations, cognitivefunction, vision deficits, and medication regimens that signal increased concern. We also found variable compliance with recommended fall prevention orders across units depending on available staffing resources and competing priorities.

Reviewing nursing documentation provided insights into human factors as well. Some falls occurred when proper assistance was not provided during high-risk activities like toileting/transfers due to staff distractions or simultaneous demands on multiple patients. Communication gaps were also implicated – like when day and night shift nurses failed to exchange all key details about fall risks during handoffs. This points to the need for more reliable standardized communication practices and enhanced teamwork/situational awareness training.

Our falls committee also probed contributing organizational factors. Workload issues, staffing shortages, and high patient volumes contributed to limited time for education, individualized care planning, and consistent implementation of nonpharmacologic fall prevention strategies. Adhering to recommended staffing ratios and skill mixes surfaced as an ongoing challenge. Equipment issues also became evident, such as nonfunctional call lights or beds/chairs lacking appropriate safety features.

This comprehensive evaluation of circumstantial, clinical, human, and system factors through huddles and reviews has generated an invaluable roadmap. We are now better positioned to implement highly targeted multi-pronged interventions shown to make the biggest impact. Actions underway include bolstering admission assessment consistency, improving communication practices, redesigning high-risk spaces, strengthening individualized care planning, enhancing staff education/competencies, and advocatingfor necessary staffing and equipment resources. With continued diligence, I’m hopeful our revised approach will yield safer patient outcomes and lower preventable fall rates over time. The insights gained through post-fall assessment refinement have certainly equipped us to move the needle on this important quality and safety issue.