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Quality improvement project eliminates falls in recovery area of high volume endoscopy unit


Background The authors' high-volume gastrointestinal endoscopy unit developed an infrastructure to track complications associated with endoscopic procedures in January of 2008. A result of this effort was the identification of a surprising number of patient falls in their recovery area. In response to this finding, the authors created and implemented a quality improvement project to eliminate patient falls in the endoscopy recovery area.

Methods The authors analysed each patient fall to try to identify the root cause in each case, and found that most falls occurred in patients of advanced age or who ambulated with an assistive device and fell while changing clothes in the bathroom unaccompanied. The authors initiated a quality improvement project to identify patients at risk of falling and to make changes in the recovery room process to minimise their risk of falling. Any patient identified as a fall risk would then be accompanied to the bathroom to change by one of the allied health staff, and they would leave the recovery area in a wheelchair. The authors used descriptive statistics to analyse age, gender, use of an assistive ambulatory device and total number of endoscopic procedures. The authors used the Fisher exact test to compare the proportion of procedures that were complicated by patient falls before and after the quality improvement intervention.

Results In 2008, the authors completed 38 370 sedated endoscopic procedures and had eight patient falls (0.02%). Three patients were female, and the mean age was 67 (range 40–96). Five of the eight patients who fell were over the age of 70 and/or used an assistive device for ambulation. All patients sustained injuries that required additional medical attention. The authors' fall prevention initiative started on 23 January 2009. From 23 January 2009 to 23 January 2010, the unit completed 42 845 sedated endoscopic procedures and had no patient falls in the endoscopic unit (p=0.002).

Conclusions These data demonstrate that a simple, low-cost intervention in a high-volume endoscopy centre can completely eliminate patient falls.

  • Adverse event
  • patient safety
  • safety culture
  • teamwork

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