Using audits and feedback to develop and refine a screening tool and safety bundle to prevent falls in the ED


Falls in the ED are a significant patient safety issue, occurring at a rate of 0.5 falls per 1,000 patient visits. Prior to this project, the UHN ED did not reliably record patient falls, lacked a tool to identify patients at risk of falls, and had no consistent bundle implemented for at-risk patients. The team undertook a literature search for existing tools, but found none that were reliable, valid and recognized for the ED. As such, they created their own tool. Multiple PDSA cycles pertaining to the exact content (sensitivity vs. specificity), format (comprehensiveness vs. usability) and medium (stickers vs. paper versions) were tested, with the current product below. Front-line nurses were engaged and their feedback was repeatedly solicited to understand the challenges of using the tool, and what improvements could be made. Informal one-on-one education sessions were organized, and audits and feedbacks were performed to improve completion of the tool and adherence to the best-practice bundle. Chart audits performed throughout the project demonstrated that screening for falls increase from 5% of patients to greater than 50%, with a commensurate increase in the measures taken to prevent such falls.


Julie Park, Fiona Muckle, Petal Samuel
Team members: Kathy Bates, Licinia Simoes, Gryan Garcia, Joel Lexchin, Monika Kapoor, Naudea Mair, Farhana Akthar
Term of project: April 2014 – May 2016