The fall electronic medical record (EMR) tracking workgroup seeks to improve communication about patient falls between clinics and those in patient care roles. The desired outcomes are prevention and reduction in patient falls whether they occur within the Vanderbilt footprint or at a local shopping mall. This information is being utilized as a key driver to better address the safety needs of patients that are ween within our organization.

A historical falls data abstraction was completed in March 2023 to capture all falls from all ambulatory care areas from the previous 2 years. During the review and analysis of the data, it became evident that multiple patients were falling more than once across our vast geographical footprint. Often there was no communication between clinics regarding the fall, and sometimes the fall was not clearly documented in the EMR. Currently, fall risk assessments within the EMR only self-populate for patients 65 years of age and older. This fall risk assessment is encounter-specific and does not populate entries made in prior visits. Adult ambulatory care fall data highlights many patients under 65 years of age that fall within our ambulatory care footprint. In the first quarter of the 2024 calendar year, 21 patients under the age of 60 experienced a fall while visiting an ambulatory care clinical area. Additionally, the Falls Identification and Reporting in the Ambulatory Setting Standard of Practice states “The fall event, the patient assessment, and any interventions are documented in the patient’s medical record.” Currently many team members are not in compliance with this policy and fail to document a patient's fall within the EMR.

Front-line staff participated in a focus group to define the current state and strategize for quality improvement. This focus group identified information that should be collected and documented following a patient's fall and would remain in the chart for one calendar year. The desire was to make this documentation as quick and easy as possible for clinical staff. There are no hard stops within the falls tracking form, and it can be accessed either from within or outside of an encounter.

The following recommendations were made by the focus group: 1) Add the falls tracking documentation form to the intake tab, 2) launch storyboard notification if a patient is positive for a fall, 3) add the falls tracking documentation form to the quick navigator for falls occurring outside of the VUMC facilities, 4) add falls tracking print group to the outpatient whiteboard snapshot report, 5) embed the patient fall icon column on the outpatient whiteboard, 6) construct a smart phrase to help standardize documentation into clinical note, and 7) review historical falls over the last calendar year in the synopsis view.

Kathleen Rynczak MSN, RN, NI-BC

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