Preventing Hospital Falls Saves Lives
Improving patient safety to save lives
Accidents in hospital contradict the entire purpose of healthcare: to make people better. Dr Nicola Burgess and Professor Graeme Currie investigated how to improve patient safety at two hospital trusts. Working closely with medical staff, the project changed attitudes to patient safety incidents (PSI) and prevented future accidents.
Treating people who fall in hospital (often the elderly), costs the NHS more than £2 billion a year. The existing tool to investigate PSIs – Root Cause Analysis (RCA) – was not fit for purpose, too often encouraging a box-ticking approach to the analysis of accidents that often does not result in improvements to services. When lessons were learnt, the information often failed to spread to other areas within the hospital. Our research team developed new processes that promoted better ways of working and disseminated knowledge more freely.
Working with Heart of England Foundation Trust (HEFT) and Nottingham University Hospitals Trust (NUHT), Dr Burgess and Professor Currie investigated some key areas of patient safety, including:
How organisational problems can prevent effective learning
The issues with the RCA process
How to best measure improvements in patient care
Development activities informed the research project, including clinical scenarios to consider the factors contributing to elderly patient falls and studies of how individuals and teams shared their knowledge.
Dr Burgess and Professor Currie’s findings have led to real improvements in HEFT and NUHT’s services.
Focus groups brought together doctors, nurses and managers to share knowledge of PSIs at the NUHT. By using actual ‘patient stories’, the effects of falls on elderly patients became clearer and more personal to clinical staff. As a result, doctors took a more active role in preventing falls and co-operating with nursing teams. Knowledge sharing between staff also improved, following a series of four workshops led by Dr Burgess at HEFT.
One key area of change concerned ‘never events’ - serious mistakes that should never occur if standards are followed properly. Fostering a ‘prosocial’ climate helped nurses to raise their concerns, whilst 350 medical staff learnt from the ‘patient story’. These improvements have directly benefited patients, with the NUHT registering a 50% drop in the number of falls, which is estimated to have prevented more than 100 hip fractures and saved 60 lives. The lessons learnt by HEFT and NUHT are now spreading further afield through professional networks keen to improve hospital care.