The organization was recording more patient falls than its leadership considered acceptable; approximately 25 falls each month. The nursing performance improvement department tracked falls and reported them to the Quality Indicator Project, a project of the Maryland Hospital Association, whose data center helps hospitals maintain, analyze and compare their quality data. SRMC found that its rate of falls was higher than average in the project's database. Falls prevalence was one of the metrics included in the nursing performance improvement dashboard adopted by the hospital in 2004, and that tool indicated that falls was an issue that needed special attention.
The hospital's multidisciplinary patient care council named a falls task force to analyze each incident, examining root causes. The work group consisted of 10 clinical managers and directors, staff representatives from the units and the patient practice and quality councils. As a result, the hospital instituted hourly rounding to check on patients, particularly those identified as fall risks. All staff were taught to be vigilant of these patients, identified with an orange armband and a falling star on the outside of their rooms.
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