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The number of falls listed for St. Cloud Hospital increased by one from last year’s report. The results cited in both were listed as serious disabilities.
“They are not as easy, in my opinion, to prevent as one might think,” Honkomp said about falls. “Sometimes our patients may be doing just fine and think that they’re able to get up on their own, only to find out that they are a little bit more dizzy than they thought and end up falling.”
St. Cloud Hospital President Craig Broman said, “I think it’s important to know that we’ve put in place many preventive measures, including doing an assessment to evaluate who are the patients that have the greatest risks of falling.”
Joy Plamann, care center director for internal medicine, chairs the hospital’s Falls Task Force. The group, with representatives from all areas of the hospital including nursing, pharmacy and physical therapy, meets monthly.
The group has revised the fall assessment tool for patients, developed annual training for the staff with emphasis on prevention and an education program for patients and their families about preventing falls in the hospital and at home.
It was also the source of a “sleep hygiene protocol,” Plamann said. Staff adjusts when sedatives are given in relation to a patient’s bedtime preparations.
“There may be link between medication and falling and sleep,” Plamann said.
Other prevention efforts include work to minimize the risk of injury in a fall, Honkomp said.
St. Cloud Hospital has done trials with beds that are lower to the ground, mats near patients’ beds that might reduce injury and alarms that sound when patients start to get out of a bed or wheelchair, she said. The trials also show how efficient and helpful the products are for hospital staff.
Links with other hospitals through the Minnesota Hospital Association let the hospital share what it has learned and learn what others find with new procedures and tests.
For example, it is involved with an MHA initiative on pressure ulcers, one of about six safety initiatives it participates in.
Pressure ulcers are one of the adverse health effects assessed by the health department’s report.
The number of stage 3, 4 or unstageable pressure ulcers at St. Cloud Hospital decreased from five in last year’s report to three.
“Learning about why events happen, then working to prevent them from happening again, is the best way to improve patient safety,” Rydrych said.
Dr. James Reinertsen, a national patient safety expert cited by the MDH, believes more adverse events could be prevented if hospital boards took stronger steps to adopt strong patient safety practices.
“I can assure you that we are using patient stories at our board meetings. One adverse health event is one too many event,” Broman said.
In the coming year, MDH and its partners will continue to focus on identifying and sharing information about risks and successful strategies for preventing serious events and promoting a statewide culture of safety.
Times Enterprise Editor Rene Kaluza contributed to this report.