Reducing Unit Falls Kaiser Permanente Los Angeles Medical

Patient Falls
Reducing Unit Falls
Kaiser Permanente Los Angeles Medical Center
Contact Information
Scott Rasgon, MD
Medical Director
Nephrology/ Dialysis Department
Kaiser Permanente LAMC
Phone: (323) 783-6195
Email: [email protected]
Type of Facility:
Number of Patients:
Number of Nephrologists:
Patient Falls
205 patients: 130 in-center; 66 PD; and 9=Home HD
10 Nephrologists and 6 Fellows
On May 2012, a double amputee, wheelchair bound patient in the in-center hemodialysis unit
fell while being weighed on a regular (not recessed) floor scale. The patient usually uses an
electrical wheelchair in the dialysis unit. However on the day when the incident occurred, the
patient came in with a regular wheel chair.
A thorough root cause analysis was immediately conducted. Based on the findings of the root
cause analysis, the Dialysis Interdisciplinary Team, Dialysis Unit Governing Body and Risk
Management developed an action plan. Safety processes for patients in wheelchairs or with
special needs, such as amputees were specified in the department’s fall policy. The last action
item in the plan, installation of a recessed floor scale, was completed in October 2013. The
completion took longer due to scale construction.
Policies and activities implemented
Dialysis Structural Standards Policy and Procedure (# 100-001) which includes fall
guideline was revised. Safety processes for patients in wheelchairs or with special
needs, such as amputees were specified in the policy.
Patient Falls
All dialysis patients shall be assessed for fall risk by a registered nurse (RN) as
Before dialysis treatment for in-center hemodialysis patients
During clinic visit for home dialysis patients
With change in patient’s mobility, mentation, elimination, medication regimen
or fall history
All dialysis patients, after a fall
All patients shall be assisted to/from and on/off the weighing scale.
The following procedure shall be followed for patients using an assistive device such
as a wheelchair, a walker or crutches:
Dialysis staff shall accompany patients upon entering and exiting the dialysis
Dialysis staff shall remain with the patient at all times while being weighed on
the scale.
Dialysis staff shall ensure that the wheelchair is locked and the brakes are on
while the patient is on the scale.
Dialysis staff shall utilize extra care and caution for patients using manual
Staff compliance was also audited to ensure that above policy was being followed.
Staff received training on the new policies and procedures during in-services, and fall guidelines
have been incorporated into the staff annual competency review. Patients receive fall prevention
handouts, which are available in English or Spanish.
From 2012 to 2013, Kaiser halved the number of patient falls, from six falls to three.
Put together a program/guideline/education for staff and patients regarding fall
Incorporate fall prevention in the Quality Assurance Performance Improvement
Program of the department.
Fall Prevention for Dialysis Patients
• A dialysis staff member
must assist you every time
you are weighed and
before and after dialysis.
• Patients with assistive
devices such as walkers,
wheelchairs, or crutches,
must be accompanied by
dialysis staff upon entering
and exiting the dialysis unit.
LAHED - 1281 (rev11/12)
Fall Prevention for Dialysis Patients
1. Make your home safer
• Keep your walkways clear. Install good lighting near any stairs.
• Use carpet on your floors. If you use a rug, make sure it’s non-slip. When you clean your floors, do not use wax.
• Secure wires and cords to the base of the wall with tape.
• Install grab bars inside and outside of the tub or shower.
2. Stay physically active
• Keep your bones and muscles strong. Keep your joints flexible. Do
activities such as walking, swimming, and dancing. Improve your
balance and strength with exercise programs like Tai Chi or Qi Gong.
• Be physically active for 30 minutes a day on most days of the week.
3. Wear the right shoes
• Wear shoes with low heels and thin, firm, non-slip soles.
• Shoes with laces or Velcro fasteners provide better support.
4. Review your medicines
• Some prescription and over-the-counter medicines can make you feel
sleepy or dizzy and increase your risk for a fall.
• Review your medicines with your doctor or pharmacist.
5. Have your vision and hearing checked
• Changes in your vision or hearing can put you at risk for a fall.
• Check your vision and hearing regularly or anytime you notice a change.
Prevención de Caídas
Para Pacientes en Diálisis
• Un miembro del personal
de diálisis debe ayudarle
cada vez que lo pesen y
antes y después de su
• Un miembro del personal
de diálisis tiene que
acompañará a los pacientes
con dispositivos de ayuda
como caminador, sillas de
ruedas, y muletas cuando entren y salgan de la unidad de
LAHED - 1282 (rev12/12)
Prevención de Caídas
Para Pacientes en Diálisis
1. Haga de su casa un lugar más seguro.
• Mantenga despejadas las áreas para caminar. Instale buena iluminación
cerca de las escaleras.
• Use alfombras en los pisos. Si usa un tapete, asegúrese de que sea
antideslizante. Cuando limpie los pisos, no los encere.
• Pegue los cables o cordones a la base de las paredes con cinta adhesiva.
• Instale barras para sujetarse dentro y fuera de la tina o regadera.
2. Manténgase activo físicamente
• Mantenga fuertes sus huesos y músculos. Mantenga flexibles las
articulaciones. Haga actividades como caminar, nadar y bailar. Mejore su
equilibrio y fortaleza con programas de ejercicios como Tai Chi o Qi Gong.
• Haga alguna actividad física durante 30 minutos la mayoría de los días
de la semana.
3. Use calzado adecuado
• Use calzado de tacón bajo y suelas delgadas, firmes y antideslizantes.
• Los zapatos con cordones o cierres Velcro ofrecen mejor apoyo.
4. Revise sus medicamentos
• Algunos medicamentos de venta con o sin receta pueden provocarle
somnolencia o mareo y aumentar su riesgo de sufrir una caída.
• Revise sus medicamentos con su médico o farmacéutico.
5. Pida que le hagan exámenes de la vista y la audición
• Los cambios en la vista o la audición también pueden ponerlo en riesgo
de sufrir caídas.
• Hágase exámenes de la vista y la audición regularmente o en cualquier
momento que note un cambio.