Falls are Wairarapa DHB’s second-most reported event in the year-to-date. PHOTO/STOCK.ADOBE.COM
Wairarapa has had an increase in patient falls, which remain a concern for the healthcare authority.
Falls were the second-most reported event in the year to date, preceded only by medication-related events, according to Wairarapa District Health Board’s August meeting paper.
“Falls prevention needs to remain a high priority further highlighted by the increase in harm from falls within our DHB,” the paper said.
The case of one inpatient, described as a “frequent faller”, required a multidisciplinary review which was nearing completion at the time of the report.
The person suffered two falls categorised as a level two in the severity assessment code while they were an inpatient from January to March this year.
The Health Quality and Safety Commission described this type of fall as one which resulted in “permanent major or temporary severe loss of function”.
The DHB was following the clinical event review process and answering questions from the patient’s family members at the time of the paper’s writing.
“The extensive timeframes for this review are due to awaiting specialist responses, the complexity of patient’s journey, and the review team availability on top of high workloads.”
DHB data against the quality and safety markers was no longer required to be submitted quarterly to the commission, the paper stated. It noted the DHB consistently achieved high results for the number of falls assessments completed and was consistently in the upper group when compared nationally.
“Individualised care plans and the use of extra high falls sheets compliance has improved. Despite this, an increase in falls with harm remained. Reminder that not only does individualised care need to be [a] documented process, it also needs to be followed through and critical thinking applied.
“Locally, a focus on falls prevention needs to be maintained as a priority. In terms of auditing, an agenda item for the next combined falls and pressure injury prevention committee is how to monitor whilst in the sustainability phase. Falls remain within Wairarapa DHB top reportable events and a rise in falls with harm has been noted.”
The report also noted recommendations from the clinical event review process would inevitably help with targeted approaches to reducing harm from falls as contributing factors, including staffing levels and patient acuity, would be investigated.
“A resourced falls educator as an interim fixed-term measure to help ascertain if this has a positive impact to patient safety in relation to falls will be further explored.”