Presentation
HE13 - Reducing Outpatient Falls: A Human Factors-Informed Fall Risk Assessment Tool
DescriptionThis work introduces a human factors-informed Outpatient Fall Risk Assessment (OFRA) tool to enable front line staff to proactively assess their outpatient spaces for work system barriers contributing to falls. Falls are among the leading causes of sentinel events over the past 5 years in both inpatient and outpatient spaces according to the Joint Commission 2022 report. Inpatient and outpatient spaces each have unique work system characteristics and, therefore, differences in characteristics that contribute to fall risk. While significant efforts have been made to reduce falls in inpatient settings at our institution, we recognized a gap in outpatient fall risk mitigation. Through this work we sought to understand the unique characteristics between inpatient and outpatient spaces, define the outpatient work system characteristics that could contribute to fall risk, and develop a tool to support front line staff at all outpatient sites to proactively investigate and mitigate fall risks.
Our team first sought to identify unique characteristics of outpatient spaces to consider what may contribute to fall risks. Drawing from extensive literature reviews, site evaluations, first-hand observations, and in-depth focus group discussions, we defined characteristics of the work system using the SEIPS model. With these characteristics in mind, we determined barriers of these characteristics and how they may contribute to a risky patient environment.
With the fall-risk-prone work system characteristics that were identified, we translated these findings into the OFRA tool to provide front line staff with considerations to assess and redesign their work systems to be human-centered and mitigate identified falls risks, thereby bolstering safety in outpatient clinics. The tool includes steps on how to conduct a fall risk assessment, work system factors to assess at each phase of the patient journey, and guiding principles to address fall risks. By creating a human-factors-informed tool that anyone could use, we hoped to expand the reach of improvement work to spaces our human factors team could not visit.
This tool underwent user testing with front line staff including nurses, office managers, reception, etc. at a wide range of outpatient clinics with specialties in ear/nose/throat, oncology, heart, and eye care among others. This testing was used to validate the tool's learnability, usability, and usefulness, and was rated positively by a diverse range of clinics and roles. Our preliminary results suggested that the tool was effective in identifying potential fall risk factors, even when used by staff who were not familiar with human factors methods.
The testing proved that the tool was effective when used by numerous roles and varying outpatient clinics. This tool has implications to be successfully used at outpatient clinics nationally where they could mimic a human factors investigation using the information provided in the tool.
The purpose of this presentation is to highlight the methods used to identify fall risk factors in outpatient settings, introduce the OFRA tool and its application, and review insights from usability testing with the tool. Lastly, we will discuss implications for this tools use in reducing fall risks at other outpatient facilities and opportunities for future work.
Our team first sought to identify unique characteristics of outpatient spaces to consider what may contribute to fall risks. Drawing from extensive literature reviews, site evaluations, first-hand observations, and in-depth focus group discussions, we defined characteristics of the work system using the SEIPS model. With these characteristics in mind, we determined barriers of these characteristics and how they may contribute to a risky patient environment.
With the fall-risk-prone work system characteristics that were identified, we translated these findings into the OFRA tool to provide front line staff with considerations to assess and redesign their work systems to be human-centered and mitigate identified falls risks, thereby bolstering safety in outpatient clinics. The tool includes steps on how to conduct a fall risk assessment, work system factors to assess at each phase of the patient journey, and guiding principles to address fall risks. By creating a human-factors-informed tool that anyone could use, we hoped to expand the reach of improvement work to spaces our human factors team could not visit.
This tool underwent user testing with front line staff including nurses, office managers, reception, etc. at a wide range of outpatient clinics with specialties in ear/nose/throat, oncology, heart, and eye care among others. This testing was used to validate the tool's learnability, usability, and usefulness, and was rated positively by a diverse range of clinics and roles. Our preliminary results suggested that the tool was effective in identifying potential fall risk factors, even when used by staff who were not familiar with human factors methods.
The testing proved that the tool was effective when used by numerous roles and varying outpatient clinics. This tool has implications to be successfully used at outpatient clinics nationally where they could mimic a human factors investigation using the information provided in the tool.
The purpose of this presentation is to highlight the methods used to identify fall risk factors in outpatient settings, introduce the OFRA tool and its application, and review insights from usability testing with the tool. Lastly, we will discuss implications for this tools use in reducing fall risks at other outpatient facilities and opportunities for future work.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives