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Creating a Standardized Post-Fall Debrief Tool: A Quality Improvement Project
Holley Farley1, Meghan Stepanek, Carla Aquino
1Office of Nursing Professional Practice, The Johns Hopkins Hospital, Baltimore, Maryland (Ms Farley and Dr Aquino); and Legal Department (Ms Stepanek) and Office of Nursing Professional Practice (Ms Whalen), The Johns Hopkins Health System, Baltimore, Maryland.
Background:
Performing post-fall debriefing improves patient outcomes through learning from defects and addresses adherence to fall prevention programs.
Local Problem:
While addressing an increase in fall rates, a quality improvement team discovered there was no standardized tool or process for completing post-fall debriefing.
Methods:
The team used the Plan-Do-Study-Act (PDSA) process to improve the post-fall debrief tool, with an analysis of pilot using the implementation science RE-AIM framework.
Interventions:
Three units with a high focus on falls and an established debriefing culture participated in pilot to generate and standardize a post-fall debrief tool.
Results:
Through 2 revisions with end user and champion feedback, the tool was refined to assess any contributing factors to the fall.
Conclusion:
Through use of the PDSA cycle, the team established content validity of the post-fall debrief tool. This tool is appropriate for inpatient adult and pediatric scale-up and complementary to current fall risk assessment tools.
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