Patient falls aren't exactly an epidemic in the ambulatory setting. In the five years that we've tracked falls, we never had more than two in a year, and some years there were none at all. But after we had what seemed like a rash of patient falls early last year - three in three months, including one that required stitches - we decided it was time for a formal falls prevention program.

We discovered that two of the patients had been here for pain management procedures and the third for an orthopedics procedure. All three had received regional nerve blocks. We also noted that several new employees had started during that time period. Was the problem with the procedures? Was staffing inadequate? Or was it a combination of factors?

The falls prevention program we instituted as a result answers these questions and more. We've had zero patient falls in the nine months since implementation, and we even won one of this year's two AAAHC Institute "Innovations in Quality Improvement" awards in the ASC category for our efforts. Here are the five keys to our success.

Don't just train, train right. We have competency checks, of course, but they were tests of knowledge, not skill. All clinical staff were rotated through the ergonomic consultant we hired. She didn't just hold classroom-style lectures about falls and body mechanics. She made staff practice the safest ways to transfer a patient from wheelchair to gurney, gurney to wheelchair and wheelchair to car, for example. (We videotaped the in-service to add to our clinical orientation.) We then tested staff in a hands-on lab and gave them a post-test written exam.

Check your PACU staffing. You probably don't have to add RNs in PACU. It's more likely that you simply need to encourage better communication and give the nurses already there the tools to do their jobs, such as transfer belts and boards. Improved communication is as simple as saying to another nurse, "I'm going to need help with this patient," or "I'll be right back." We have also appointed two staff lift champions on site to act as the in-house ergonomics consultants. They received special training so they can provide on-the-spot education and correction when they observe inappropriate technique or a lack of communication.

Tout the benefits. This isn't just a patient safety issue - it's an employee health issue. Too many nurses leave the field each year due to disabling back, shoulder, knee and arm injuries, and it doesn't need to be that way. Stress to your nurses that you want them to go home pain-free each day, and that fall-prevention efforts are part of that goal.

Change your policies. We instituted four hard-and-fast rules for PACU staff.

• Keep gurney side rails up at all times. Never leave a patient unattended if the side rails are down.
• Don't leave a patient unattended when he's getting dressed - assume he's weak and numb, even if he says otherwise.
• Keep the wheelchair near the patient. This makes it easier to directly assist him into it.
• When moving a patient, position yourself in front of him, placing your hands in the axillary area to guide him to standing or sitting.

Change patient teaching. Patients leaving soon after any kind of anesthesia, especially regional, are at high risk for falls, both because of the effects of the drugs and the fact that outpatients often underestimate the seriousness of their "minor" procedures. Pre- and post-op, we now detail for patient and escort what to expect from a block and how to keep safe at home until the block wears off. We've also started putting large stickers on discharge forms to remind patients of their instructions.

Yes, falls happen, but...
Unfortunately, even one fall can be devastating to your facility, not to mention the patient. But there's lots of information out there from researchers and accrediting and quality improvement bodies regarding patient safety - embrace it as an opportunity for improvement.