Page 55 - Q BULLETIN, Ministry of Health Malaysia, VOLUME 1, NO. 31 (SUPPLEMENT 1), JAN-DEC 2022

Q Bulletin, Volume 1, No. 31 (Supplement 1), Jan - Dec 2022
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11 National QA Convention, 4 – 6 October 2022
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Prevention and Intervention Measures towards Reducing Fall Incidents at Avisena
Healthcare

Azlyanna AA, Marina I, Rafizah R, Siti Katijah Y, Nur Aqilah NAN
Avisena Healthcare, Selangor

SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
Fall incident was one of the highest 2019 incidents in Avisena Healthcare, with 14 falls involving inpatients.
This study aimed to prevent fall incidents which may lead to prolonged hospitalisation and additional medical
expenses for patients.

KEY MEASURES FOR IMPROVEMENT:
The indicator is calculated from the total patient falls over the total admission from 2019 to 2021. The standard
is set at zero incident rate.

PROCESS OF GATHERING INFORMATION:
Data were compiled for falls in Paediatric, Medical and Surgical Wards using the Patient Safety Incident
Report Form. The study was conducted from 2019-2021. Analysis was performed using London Protocol Root
Cause Analysis Investigation Tools. Fall incident was discussed in the Incident Report meeting and cascaded
to the departmental level for awareness and learning points.

ANALYSIS AND INTERPRETATION:
Eighteen toddlers and 16 adults’ fall incidents were recorded in 2019-2021. All toddler falls happened while
patients were inside their room with their parents at a rate of 0.035%. All adult patients fall of their own accord
despite reminders to call for assistance, involving one post-surgery patient with a rate of 0.0019%. Thirteen
patients with co-morbidities at the rate of 0.025%, and two adult patients fall due to faulty fittings at the rate
of 0.003%.

STRATEGIES FOR CHANGE:
Strategies implemented since 2019 include a briefing on fall prevention to patient and guardian upon admission,
display of posters in patient’s room and close supervision for elderly and post-surgery patients. A pilot project
installing anti-slip materials was implemented in 2021 to prevent falls inside patients’ toilets.

EFFECT OF CHANGE:
The total fall incidents were reduced from fourteen in 2019 to thirteen in 2020 and seven in 2021. It is equivalent
to a fall rate of 0.09% in 2019, reduced to 0.08% in 2020 and reduced further to 0.04% in 2021.

THE NEXT STEP:
Avisena Healthcare will continue to monitor the effectiveness of fall preventive measures toward sustainable
reduction in fall incidents in subsequent years.

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