Clinical Review
Redesigning the Fall Incident Report
A Safety Initiative
Fed Pract. 2004 March;21(3):29
Author and Disclosure Information
Joanne Elkins, MSN, RN, CPHQ, Lula Williams, MN, RN, CPHQ, Andrea M. Spehar, MS, DVM, MPH, Patricia A. Quigley, PhD, ARNP, CRRN, Tamala Gulley, MSCE, and Josefina Perez-Marrero, PhD
Ms. Elkins is a quality systems coordinator and Ms. Williams is a utilization manager, both at the Bay Pines VA Medical Center, Bay Pines, FL. Dr. Spehar is a project manager and Dr. Quigley is an associate director of the clinical division at the Veterans Integrated Service Network 8 Patient Safety Center of Inquiry, both at the James A. Haley Veterans' Hospital, Tampa, FL. Ms. Gulley is an industrial engineer and, at the time of submission, Dr. Perez-Marrero was a research assistant, both at the Bay Pines VA Medical Center.
Representing up to 89% of all reported adverse clinical incidents, falls are costly in both human and financial terms. Here's how VISN 8 transformed their fall reporting process so that it could be used to drive system changes that would prevent falls.