Clinical Decision Support for Nurses: A Fall Risk and Prevention Example.

Area of Science:

• Nursing
• Health Informatics
• Patient Safety

Background:

• Clinical decision support (CDS) tools in electronic health records (EHRs) enhance process measures and clinician performance.
• Patient fall risk identification and prevention are significant concerns for nursing staff.
• CDS tools present an opportunity to improve nursing compliance with fall prevention protocols.

Purpose of the Study:

• To evaluate the impact of a CDS tool on nurse compliance with fall risk assessments and prevention plans of care.
• To determine if CDS implementation affects patient fall rates and falls with injury.

Main Methods:

• A quality improvement project was conducted across 16 adult inpatient units.
• The project utilized CDS to prompt nurses for fall risk assessments and care plans.
• Data were collected through quarterly audits, retrospective chart reviews, safety reports, and analysis of falls and falls-with-injury rates before and after CDS implementation.

Main Results:

• Nurse compliance with documented fall risk assessments significantly improved (P = .05).
• Documentation rates for fall prevention plans of care did not show significant improvement.
• Patient falls and falls with injury rates did not significantly change post-intervention.

Conclusions:

• CDS tools can effectively improve documentation of fall risk assessments in inpatient settings.
• Further strategies are needed to ensure consistent documentation and implementation of fall prevention plans of care.
• The direct impact of improved assessment documentation on fall rates requires further investigation.