But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Thursday, April 12, 2007


Hospitals do all they can to avoid patient falls. Falls can lead to minor cuts and bruises, but they can also cause serious injuries. It is a cruel irony to be injured in a fall when you are being cured in a hospital.

All falls are recorded to evaluate what happened and why. One of our folks was recently looking through our reports and noticed a pattern. Three people had recently suffered falls just as they were about to be discharged. No, not after they left their room and were heading home. But while they were sitting on the edge of their bed, fully clothed, ready to go.

What was happening here? We think that our staff members were receiving a subliminal message: They would see a healthy, dressed person in the room and might not have paid the same degree of attention to the patient as they would have an hour earlier when he or she might have been sitting on the edge of the bed in a hospital gown. Slight dizziness or instability of this person would then lead to the fall.

So, now we have circulated the word to the floors to be alert to this possibility, and we are hoping to see a difference. This takes no major effort, just an extra bit of attention at the right time.

Unexpected problem, good analytical pickup by one of our quality and safety staffers, and a simple solution. Not all safety improvements require a huge effort.

I'm curious whether other hospital folks out there have seen this particular phenomenon, too, and, if so, what you did about it. Ditto for other types of safety and quality observations

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