171 - Don’t Let Me Down: Falls Prevention in the Operating Room
Description: Falls are not common in the operating room (OR) setting, but can be devastating when they do occur, resulting in serious injuries or even death. The Joint Commission found that the most common causes of patient falls in the hospital setting include miscommunication, protocol deviations, and deficiencies in the physical environment. These factors are part of what led to a patient fall in the operating room during a post-operative transfer of a patient from the operating table to the stretcher. This quality improvement project describes a patient fall in the OR at Emory University Hospital. A root cause analysis performed after the patient fall revealed process failures and areas for mitigation opportunities. This led to the creation of a Patient Transfer Algorithm to improve team communication and safety of patient transfer. Signs were placed in each OR to be utilized for each patient transfer, verbalized audibly by the anesthesia provider. Training videos were shown to staff members and are now used for new employee training. Since implementing this test of change, there have been no patient falls reported in the operating room.