SVILUPPO DEL PROGETTO DI PREVENZIONE DEL RISCHIO DI CADUTA PRESSO L AZIENDA OSPEDALIERA CARLO POMA AZIENDA OSPEDALIERA CARLO POMA

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1 SVILUPPO DEL PROGETTO DI PREVENZIONE DEL RISCHIO DI CADUTA PRESSO L AZIENDA OSPEDALIERA CARLO POMA Burato E *, Borsatti G*, Barbera A*, Superbi P **, Lorenzoni M **, Ferraro F ***, Mantovani A, Bedotti F, Anselmi A, Bigi G, Bolognini M, Cacciamani R, Casaroli R, Fili ppi B, Martinelli C, Mondini M, Montani R, Ravelli A, Rosa R, Bernabeni L, Sarzi Puttini S, Carraro M, Tambani E, Storti PV** * Struttura Qualità, Accreditamento e Controllo Strategico, Azienda Ospedaliera Carlo Poma di Mantova ** Direzione Sanitaria, Azienda Ospedaliera Carlo Poma di Mantova *** Struttura di Riabilitazione Neuromotoria, Azienda Ospedaliera Carlo Poma di Mantova Servizio Infermieristico Tecnico Riabilitativo Azi endale, Azienda Ospedaliera Carlo Poma di Mantova Gruppo di lavoro Aziendale sulla prevenzione delle cadute accidentali OBJECTIVES In range of the annual plan of risk management of the AO C.Poma of Mantua, has been created a two-year project with the purpose of developing strategies for analysis and prevention of adverse events related to accidental falls of patients and visitors. These events represent the third ground of claim for damages and the corporate security policy has always been oriented to the ministerial recommendations regarding clinical safety as well as international targets for patient safety JCI according to the three-year project for the evaluation of healthcompanies accredited of Lombardy Region. METHODS The project includes the establishment of a multidisciplinary working group accredited with ECM, which saw the participation of the Health Department, the Risk Manager, the SITRA and nurses representing all health departments and the Director of the Neuromotor Rehabilitation. The group had the task of analyzing about 890 cases of fall events for patients and visitors from the year 2005 to the first half of, considering age, mode of occurrence, dynamic event, intrinsic and extrinsic factors that may have contributed to 'event (including morbid condition, current treatment, and environmental conditions), the consequences for the patient, costs and connection with the events that gave rise to the claim. generato il sinistro. RESULTS It was produced a semi-annual report of the events discussed with the risk manager and Department Heads and RAD (Figures 1 and 2), which has allowed the implementation of a new survey form (Figure 3) (also connected to reporting of sentinel events) as well as new specific procedure shared which has adopted the evaluation scale of Conley for all wards with the exception of rehabilitations in which has been adapted a scale of Conley amended in line with the international recommendations for safety. It was produced a poster informative tips for the user (Figure 4) and was finally produced a survey form environmental risks, shared with the RSPP, which is compiled annually by the coordinators of wards and analyzed by the group of companies. These initiatives cone was disclosed in specific training worshop open to health care professionals. Figura 1: Report semestrale Cadute Accidentali AZIENDA OSPEDALIERA CARLO POMA CADUTE ACCIDENTALI ANNI (TOT 840) MANTOVA ASOLA BOZZOLO PIEVE AZIENDALE Sem Sem Sem Sem Sem 2 Sem Figura 2: Analisi dell andamento Cadute presso l Azienda Ospedaliera Carlo Poma, CONCLUSIONS This common model allows real-time measurement of the phenomenon but also the effectiveness of preventive measures. Figura 3: Scheda di rilevazione Cadute Figura 3: Poster informativo per l utenza

2 ! AVOID UNNECESSARY RISKS OF FALLING Dear guest, the risk of falls in hospital is an event possible and common to all patients whether they are self-reliant whether they are autonomous in the movements. These simple tips are meant to make you avoid unnecessary risks For this WEAR CLOSED SLIPPERS, IF POSSIBLE with SOLE-SLIP RUBBER OUTSOLE, and DRESSING GOWNS NOT TOO LONG ALWAYS FOLLOW THE CARE TEAM S (DOCTORS, NURSES,ETC) DIRECTIONS REGARDING YOUR POSSIBILITY OF MOVEMENT MAKE SURE THAT THE ROOM IS ALWAYS PROPERLY ILLUMINATED! MOVING IN THE DARK YOU MIGHT BUMP AGAINST SOME OBSTACLE, OR STUMBLE THE BATHROOM IS THE PLACE WHERE SPILLS CAN BE MORE DANGEROUS IF YOU DON'T FEEL SAFE WALKING OR IF YOU FEEL DIZZY MADE ASSIST by WARD STAFF IF YOU ARE TIRED USES A WHEELCHAIR TO MOVE FROM A ROOM TO ANOTHER OR TO WALK EVEN SHORT DISTANCES; ESPECIALLY AT NIGHT, ALWAYS ASKING OPERATORS HELP EXPOSE YOUR PROBLEMS ABOUT YOUR MOVEMENTS TO DEPARTMENT S OPERATORS, THET WILL HELP YOU, IF NECESSARY, TO OBTAIN THE DEVIDES THAT ALLOW YOU TO MAINTAIN YOUR AUTONOMY, BOTH IN THE HOSPITAL AND RETURN HOME WHEN YOU MOVE OR TURN OVER, BE CAREFUL Your cooperation is essential to avoid any risk of accidental falls safeguarding your health. To help you, operators are at your disposal at all times. THANK YOIU BY THE GROUP FOR IMPROVEMENT AO C. Poma "PREVENT ACCIDENTAL FALLS" (GAD falls)

3 AVOID UNNCESSARY RISKS OF FALLING Dear Mum and Dad, children s safety going through your help to observe some simple advices It s very important to adopt some effective measures of attention For this DO NOT LEAVE YOUR CHILD UNATTENDED IN THE ROOM, ON A CHANGING TABLE, LIBRA, STROLLER, IN THE CRIB BARS IF NOT INDICATED MAY BECOME A DANGER; MAY SURE THAT YOUR BABY WEARS CLOSED SLIPPERS IF POSSIBLE with SOLE SLIP RUBBER AND MAKE SURE THAT YOUR BABY DOESN T RUN INSIDE THE HOSPITAL OR CLIMB ON FURNITURE OR USE THEM IMPROPERLY PAY ATTENTION TO MEDICAL DEVICES, SOME OF WHICH CAN INCREASE THE RISK OF FALLING (E.G., CATHETERS, OXYGEN, MONITORS, INFUSION PUMPS,CASTAS OR SPLINTS ) REMEMBER THAT IT IS FORBIDDEN FOR CHILDREN TO USE THE BEDS REMOTE CONTROL; NEVER LEAVE "DANGEROUS" OBJECTS NEAR TO CHILDREN LIKE DRIVING GAMES, ETC.; ATTEND YOUR CHILD DURING WALKING ESPACIALLY TO THE BATHROOM: THIS IS THE AREA IN WHICH FALL S RISK IS MOST DANGEROUS IF YOUR CHILD HAS BEEN LYING FOR A LONG TIME, MIGHT HAVE DIZZINESS STANDING UP TOO QUICKLY: SIT HIM/HER FOR A FEW MINUTES BEFORE RAISE DON T CARRY YOUR CHILD FROM A ROOM TO ANOTHER AREA HOLDING IT YOUR ARMSAND REMEMBER THAT WHEN YOU TAKE IN THE ARM IS, THE SITTING POSITION IS RECOMMENDED ; WET FLOOR CAN FACILITATE FALLS DO NOT LEAVE CHAIRS IN FRONT OF TABLES, SHELVES OR WINDOWS and IF YOU MUST DO IT DON T LEAVE YOUR CHILD UNATTENDED IF YOU ARE CONCERNED OF YOUR CHILD S RISK FALLING, INFORM STAFF IMMEDIATLY Your cooperation is essential to avoid any risk of accidental falls safeguarding your health. To help you, operators are at your disposal at all times. THANK YOU BY THE GROUP FOR IMPROVEMENT AO C. Poma "PREVENT ACCIDENTAL FALLS" (GAD falls).

4 DATA REPORTING LOMBARDY REGION REFERENCE PERIOD: YEAR YEAR YEAR YEAR EVALUATION SETTING TYPE OF EVENT: FALLS WARDS INVOLVED: ALL PERFORMANCE IN TIME MANTOVA ASOLA BOZZOLO PIEVE AZIENDALE AZIENDA OSPEDALIERA CARLO POMA CADUTE ACCIDENTALI ANNI M ANTOVA ASOLA BOZZOLO PIEVE AZIENDALE 50 0 M ANTOVA ASOLA BOZZOLO PIEVE AZIENDALE Description reports from to show a high, but steady number of records, especially in some wards, due in particular to the type of patients in care. Compared to 1 semester still high the number of falls with severe/serious prognosis, but in sharp decline (-50% compared to previous year) due to operators' awareness achieved through departmental meetings during which was filed reporting linked to the phenomenon "accidental fall" and during which was reaffirmed the importance of correct compilation of clinical documentation.

5 SVILUPPO DEL PROGETTO DI PREVENZIONE DEL RISCHIO DI CADUTA PRESSO L AZIENDA OSPEDALIERA CARLO POMA Burato E *, Borsatti G*, Barbera A*, Superbi P **, Lorenzoni M **, Ferraro F ***, Mantovani A, Bedotti F, Anselmi A, Bigi G, Bolognini M, Cacciamani R, Casaroli R, Fili ppi B, Martinelli C, Mondini M, Montani R, Ravelli A, Rosa R, Bernabeni L, Sarzi Puttini S, Carraro M, Tambani E, Storti PV** * Struttura Qualità, Accreditamento e Controllo Strategico, Azienda Ospedaliera Carlo Poma di Mantova ** Direzione Sanitaria, Azienda Ospedaliera Carlo Poma di Mantova *** Struttura di Riabilitazione Neuromotoria, Azienda Ospedaliera Carlo Poma di Mantova Servizio Infermieristico Tecnico Riabilitativo Azi endale, Azienda Ospedaliera Carlo Poma di Mantova Gruppo di lavoro Aziendale sulla prevenzione delle cadute accidentali OBJECTIVES In range of the annual plan of risk management of the AO C.Poma of Mantua, has been created a two-year project with the purpose of developing strategies for analysis and prevention of adverse events related to accidental falls of patients and visitors. These events represent the third ground of claim for damages and the corporate security policy has always been oriented to the ministerial recommendations regarding clinical safety as well as international targets for patient safety JCI according to the three-year project for the evaluation of healthcompanies accredited of Lombardy Region. METHODS The project includes the establishment of a multidisciplinary working group accredited with ECM, which saw the participation of the Health Department, the Risk Manager, the SITRA and nurses representing all health departments and the Director of the Neuromotor Rehabilitation. The group had the task of analyzing about 890 cases of fall events for patients and visitors from the year 2005 to the first half of, considering age, mode of occurrence, dynamic event, intrinsic and extrinsic factors that may have contributed to 'event (including morbid condition, current treatment, and environmental conditions), the consequences for the patient, costs and connection with the events that gave rise to the claim. generato il sinistro. RESULTS It was produced a semi-annual report of the events discussed with the risk manager and Department Heads and RAD (Figures 1 and 2), which has allowed the implementation of a new survey form (Figure 3) (also connected to reporting of sentinel events) as well as new specific procedure shared which has adopted the evaluation scale of Conley for all wards with the exception of rehabilitations in which has been adapted a scale of Conley amended in line with the international recommendations for safety. It was produced a poster informative tips for the user (Figure 4) and was finally produced a survey form environmental risks, shared with the RSPP, which is compiled annually by the coordinators of wards and analyzed by the group of companies. These initiatives cone was disclosed in specific training worshop open to health care professionals. Figura 1: Report semestrale Cadute Accidentali AZIENDA OSPEDALIERA CARLO POMA CADUTE ACCIDENTALI ANNI (TOT 840) MANTOVA ASOLA BOZZOLO PIEVE AZIENDALE Sem Sem Sem Sem Sem 2 Sem Figura 2: Analisi dell andamento Cadute presso l Azienda Ospedaliera Carlo Poma, CONCLUSIONS This common model allows real-time measurement of the phenomenon but also the effectiveness of preventive measures. Figura 3: Scheda di rilevazione Cadute Figura 3: Poster informativo per l utenza

6 ! AVOID UNNECESSARY RISKS OF FALLING Dear guest, the risk of falls in hospital is an event possible and common to all patients whether they are self-reliant whether they are autonomous in the movements. These simple tips are meant to make you avoid unnecessary risks For this WEAR CLOSED SLIPPERS, IF POSSIBLE with SOLE-SLIP RUBBER OUTSOLE, and DRESSING GOWNS NOT TOO LONG ALWAYS FOLLOW THE CARE TEAM S (DOCTORS, NURSES,ETC) DIRECTIONS REGARDING YOUR POSSIBILITY OF MOVEMENT MAKE SURE THAT THE ROOM IS ALWAYS PROPERLY ILLUMINATED! MOVING IN THE DARK YOU MIGHT BUMP AGAINST SOME OBSTACLE, OR STUMBLE THE BATHROOM IS THE PLACE WHERE SPILLS CAN BE MORE DANGEROUS IF YOU DON'T FEEL SAFE WALKING OR IF YOU FEEL DIZZY MADE ASSIST by WARD STAFF IF YOU ARE TIRED USES A WHEELCHAIR TO MOVE FROM A ROOM TO ANOTHER OR TO WALK EVEN SHORT DISTANCES; ESPECIALLY AT NIGHT, ALWAYS ASKING OPERATORS HELP EXPOSE YOUR PROBLEMS ABOUT YOUR MOVEMENTS TO DEPARTMENT S OPERATORS, THET WILL HELP YOU, IF NECESSARY, TO OBTAIN THE DEVIDES THAT ALLOW YOU TO MAINTAIN YOUR AUTONOMY, BOTH IN THE HOSPITAL AND RETURN HOME WHEN YOU MOVE OR TURN OVER, BE CAREFUL Your cooperation is essential to avoid any risk of accidental falls safeguarding your health. To help you, operators are at your disposal at all times. THANK YOIU BY THE GROUP FOR IMPROVEMENT AO C. Poma "PREVENT ACCIDENTAL FALLS" (GAD falls)

7 AVOID UNNCESSARY RISKS OF FALLING Dear Mum and Dad, children s safety going through your help to observe some simple advices It s very important to adopt some effective measures of attention For this DO NOT LEAVE YOUR CHILD UNATTENDED IN THE ROOM, ON A CHANGING TABLE, LIBRA, STROLLER, IN THE CRIB BARS IF NOT INDICATED MAY BECOME A DANGER; MAY SURE THAT YOUR BABY WEARS CLOSED SLIPPERS IF POSSIBLE with SOLE SLIP RUBBER AND MAKE SURE THAT YOUR BABY DOESN T RUN INSIDE THE HOSPITAL OR CLIMB ON FURNITURE OR USE THEM IMPROPERLY PAY ATTENTION TO MEDICAL DEVICES, SOME OF WHICH CAN INCREASE THE RISK OF FALLING (E.G., CATHETERS, OXYGEN, MONITORS, INFUSION PUMPS,CASTAS OR SPLINTS ) REMEMBER THAT IT IS FORBIDDEN FOR CHILDREN TO USE THE BEDS REMOTE CONTROL; NEVER LEAVE "DANGEROUS" OBJECTS NEAR TO CHILDREN LIKE DRIVING GAMES, ETC.; ATTEND YOUR CHILD DURING WALKING ESPACIALLY TO THE BATHROOM: THIS IS THE AREA IN WHICH FALL S RISK IS MOST DANGEROUS IF YOUR CHILD HAS BEEN LYING FOR A LONG TIME, MIGHT HAVE DIZZINESS STANDING UP TOO QUICKLY: SIT HIM/HER FOR A FEW MINUTES BEFORE RAISE DON T CARRY YOUR CHILD FROM A ROOM TO ANOTHER AREA HOLDING IT YOUR ARMSAND REMEMBER THAT WHEN YOU TAKE IN THE ARM IS, THE SITTING POSITION IS RECOMMENDED ; WET FLOOR CAN FACILITATE FALLS DO NOT LEAVE CHAIRS IN FRONT OF TABLES, SHELVES OR WINDOWS and IF YOU MUST DO IT DON T LEAVE YOUR CHILD UNATTENDED IF YOU ARE CONCERNED OF YOUR CHILD S RISK FALLING, INFORM STAFF IMMEDIATLY Your cooperation is essential to avoid any risk of accidental falls safeguarding your health. To help you, operators are at your disposal at all times. THANK YOU BY THE GROUP FOR IMPROVEMENT AO C. Poma "PREVENT ACCIDENTAL FALLS" (GAD falls).

8 DATA REPORTING LOMBARDY REGION REFERENCE PERIOD: YEAR YEAR YEAR YEAR EVALUATION SETTING TYPE OF EVENT: FALLS WARDS INVOLVED: ALL PERFORMANCE IN TIME MANTOVA ASOLA BOZZOLO PIEVE AZIENDALE AZIENDA OSPEDALIERA CARLO POMA CADUTE ACCIDENTALI ANNI M ANTOVA ASOLA BOZZOLO PIEVE AZIENDALE 50 0 M ANTOVA ASOLA BOZZOLO PIEVE AZIENDALE Description reports from to show a high, but steady number of records, especially in some wards, due in particular to the type of patients in care. Compared to 1 semester still high the number of falls with severe/serious prognosis, but in sharp decline (-50% compared to previous year) due to operators' awareness achieved through departmental meetings during which was filed reporting linked to the phenomenon "accidental fall" and during which was reaffirmed the importance of correct compilation of clinical documentation.