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DTSTAMP:20240325T185834Z
LOCATION:Salon C
DTSTART;TZID=America/Chicago:20240325T164500
DTEND;TZID=America/Chicago:20240325T181500
UID:HFESHCS_2024 International Symposium on Human Factors and Ergonomics i
 n Health Care_sess111_POST215@linklings.com
SUMMARY:HE13 - Reducing Outpatient Falls: A Human Factors-Informed Fall Ri
 sk Assessment Tool
DESCRIPTION:Poster Presentation\n\nAllison Drees and Yushi Yang (Johns Hop
 kins Health System) and Lewis Heinlein (Johns Hopkins University)\n\nThis 
 work introduces a human factors-informed Outpatient Fall Risk Assessment (
 OFRA) tool to enable front line staff to proactively assess their outpatie
 nt spaces for work system barriers contributing to falls. Falls are among 
 the leading causes of sentinel events over the past 5 years in both inpati
 ent and outpatient spaces according to the Joint Commission 2022 report. I
 npatient and outpatient spaces each have unique work system characteristic
 s and, therefore, differences in characteristics that contribute to fall r
 isk. 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 character
 istics 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 in
 vestigate and mitigate fall risks.\n\nOur team first sought to identify un
 ique 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 define
 d characteristics of the work system using the SEIPS model. With these cha
 racteristics in mind, we determined barriers of these characteristics and 
 how they may contribute to a risky patient environment.\n\nWith the fall-r
 isk-prone work system characteristics that were identified, we translated 
 these findings into the OFRA tool to provide front line staff with conside
 rations 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 g
 uiding principles to address fall risks. By creating a human-factors-infor
 med tool that anyone could use, we hoped to expand the reach of improvemen
 t work to spaces our human factors team could not visit.\n\nThis tool unde
 rwent user testing with front line staff including nurses, office managers
 , reception, etc. at a wide range of outpatient clinics with specialties i
 n ear/nose/throat, oncology, heart, and eye care among others. This testin
 g was used to validate the tool's learnability, usability, and usefulness,
  and was rated positively by a diverse range of clinics and roles. Our pre
 liminary results suggested that the tool was effective in identifying pote
 ntial fall risk factors, even when used by staff who were not familiar wit
 h human factors methods.\n\nThe 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 whe
 re they could mimic a human factors investigation using the information pr
 ovided in the tool.\n\nThe purpose of this presentation is to highlight th
 e methods used to identify fall risk factors in outpatient settings, intro
 duce the OFRA tool and its application, and review insights from usability
  testing with the tool. Lastly, we will discuss implications for this tool
 s use in reducing fall risks at other outpatient facilities and opportunit
 ies for future work.\n\nTrack: Digital Health, Simulation and Education, H
 ospital Environments, Medical and Drug Delivery Devices, Patient Safety Re
 search and Initiatives
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