Enhancing Patient Safety: A Pilot Program to Reduce Falls by Improving Communication Among Nursing Assistants on an Oncology Unit,
Publication Date
2025
Journal Title
40th Annual Joseph L. Belsky, MD Research and Clinical Trials Day Danbury Hospital
Abstract
Effective communication between nurses and ancillary staff (PCTs) during change of shift handover is a determinant of patient safety. Handover error or omission is one of the root causes of sentinel events, especially falls with injury. This study examined the reporting practices of PCTs on the oncology unit in a 300-bed hospital. The largest gap was found in how fall risk status and prevention information is communicated between PCTs, and between PCTs and nurses. The aim of this project is to address the absence of fall risk communication, to examine PCT knowledge of fall risk factors, and to identify gaps in their practice regarding fall prevention. The authors theorized that the introduction of a new form detailing fall risk, and its prevention would improve communication during the handoff process. Post-introduction findings of the new handover sheet show that shared communication among team members improved outcomes, reflected in the reduction of falls with injury. 12 PCTs received an informal questionnaire. Five PCTs (42%) were unable to identify fall risk factors or prevention strategies. Eleven nurses completed a 10-item fall-related knowledge assessment and fall prevention self-efficacy tool. Sixty-one percent revealed they did not always receive fall information from the previous shift and therefore were not prepared to share information with PCTs.
Document Type
Poster
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