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Post-Fall Management for Rehabilitation Nurses

presented by Pat Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP

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Disclosure Statement:

Financial: Pat Quigley receives compensation from MedBridge for this course. She is also an independent contractor for the following: American Hospital Association, Hospital Research and Education Trust; Washington Hospital Association, Hospital Improvement and Innovation Network; AvaSure, LLC; HD Nursing, LLC.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

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Accreditation Check:

All organizations strive for falls to be "never events" in health care. However, falls remain among the top adverse events patients experience in hospitals and nursing homes. When a fall occurs, interventions must be implemented to decrease the chance of reoccurrence. During this course, rehabilitation nurses will: discuss the role of a post-fall huddle as a group consensus approach to determine the immediate/root cause of the fall; differentiate the post-fall huddle from other post-fall management components (incident reports and medical record documentation); and illustrate a post-fall huddle program evaluation model.

Meet Your Instructor

Pat Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP

Dr. Patricia Quigley, PhD, MPH, APRN, CRRN, FAAN, FAANP, Nurse Consultant, is a retired Associate Director of the VISN 8 Patient Safety Research Center of Inquiry and is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation. Her contributions to patient safety, nursing, and rehabilitation are evident at a national level, with emphasis…

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Chapters & Learning Objectives

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1. Conducting the Post-Fall Huddle

When a patient fall occurs, staff members make every effort to immediately respond. They assess the patient’s status upon rescue, uncover the circumstances of the fall, and then decide on appropriate care management. A group of providers struggle to ascertain the immediate or root cause of the fall. Acknowledging that 80% to 90% of falls that happen in hospitals are unwitnessed (Oliver, et al., 2010), patient involvement in the post-fall huddle is essential. This chapter dramatizes the conduct of an actual post fall huddle following a patient fall.

2. Post-Fall Management: The Role of the Post-Fall Huddle

A fall event generates an organizational response to investigate and understand all the contributing circumstances of the fall. This organizational response is observable through various communication systems: huddles, post-fall assessment, incident reports, and hand-off communication. In this chapter, rehabilitation nurses will distinguish the value of each component of post-fall management and the unique purpose of the post-fall huddle as the first action from all other huddles, outline the eight steps of the post-fall huddle process, utilize accident theory to visualize the complexity of immediate/root cause determination.

3. Program Evaluation: Added Precision to Understanding Falls

Program evaluation is a detailed and comprehensive process that includes formative and summative components. Fall rates, as an outcome, are insufficient to examine the effectiveness of fall prevention. Rather, the post-fall huddle should be examined as a program intervention that, when implemented provides increased depth and breadth to understanding patient falls. During this chapter, rehabilitation nurses will learn a detailed program evaluation model applied to post-fall huddle to determine efficiency and effectiveness.

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