Since 2011, falls have been one of the most common causes of adverse events and have slightly increased every year (MSSS: 2011-2016. During the review process, we found that the corrective measures put in place have a minimal impact on the number of falls. There is only a partial picture of the problem, as well as a lack of involvement of the users/families and friends and the interdisciplinary team in the review process.
Given this problem, the aim of this improvement project is to involve the user, his or her family and the interdisciplinary team in analyzing an adverse event. The goal was to “decrease by 15%” the rate of falls and resulting injuries in a living unit at CHSLD [Centres d’hébergement de soins de longue durée (nursing homes)]. The target was surpassed with a decrease of 27% in the rate of falls, thanks to the following ideas for changes:
- Involving the resource user in committees;
- Involving the resource user and their family and friends in the review process for falls;
- Involving the interdisciplinary team in the review process by setting up the quality/security caucus, using the security cross and intentional rounds.
Specifically, the project team reinvented the use of the AH-223 as a clinical and inclusive lever for the voice of the user and his or her family to improve the quality and safety of care and services.
In addition, the user and his or her family cooperate in defining individualized actions for improvement to prevent falls from recurring, which produced concrete results. The pilot project has been rolled out in all living units of the 16 CHSLDs of the CISSS of Montérégie-Est.