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Breaking the Falls

If you ask Patsy Manson, RN, Northern Light Sebasticook Valley Hospital (SVH), what the best part of her job is, she’d respond without hesitation, “I really enjoy talking to the patients. I'm very—well, maybe overly—talkative at times,” Patsy jokes. “I really like getting to know all of them.”

Patsy knows—after a career of caring for patients—that the more you get to know a patient, the better their care can be, which includes understanding how to keep them safe from preventable harm like falling while in the hospital.

A fall isn’t the typical embarrassing stumble we experience from time to time. A fall may result in fractures, lacerations, or internal bleeding. “It can really slow a person's healing and recovery and set them back,” says Kristi Fogler, PT and previous director of Rehabilitation at SVH. “The effect of falls is very grave.”

SVH, like all hospitals in our state and the country, experiences patient falls despite the policies and procedures in place to prevent them. However, a new pilot program at Northern Light Health gave the hospital a fresh approach to this serious problem.

“We spoke with staff and asked the simple question, ‘How do you think we're going to hurt the next patient on our unit?’ Overwhelmingly falls was the number one answer,” said Tracy Bonney-Corson, RN, MSN, MHA-H, vice president nursing and patient care services at SVH. Asking this important question was the first step in the Comprehensive Unit-Based Safety Program (CUSP) developed by the Johns Hopkins Armstrong Institute for Patient Safety and Quality. CUSP is a performance improvement model designed to put patient safety in the hands of frontline team members.

“The intent is to design, grow, and expand the CUSP program across our member organizations and across the system,” says Tracy. Working from the direct feedback of the frontline staff, SVH decided to use the CUSP model to address patient falls. The first thing the team realized was not all the necessary disciplines were at the table when discussing solutions, like the Rehabilitation Department.

 “The biggest thing that we noticed was that there was a difference of language between healthcare disciplines. Nurses spoke a certain language, therapists spoke a different language, and yet we worked with the same patient,” remarks Kristi.

The SVH CUSP team also engaged SVH’s Patient and Family Advisory Committee for Quality and Safety on the initiative. This dedicated group provided feedback from the patient and family perspective on improvement strategies and suggested enhancements to signage and white board communications. 

“We use safety cards, a standardized assessment tool of a patient's mobility, that will be used by both nurses and therapist alike,” Kristi explains. “These safety cards are placed directly on the whiteboards and are color coordinated with the patient's assessment level so we can better understand at a glance what the patient needs.”

Tracy says that she has always known that no one understands better than the care team working with patients how we’re putting them at risk and how best to prevent harm. “We have seen a reduction in falls on our medical surgical unit as a result of the program. Equally as valuable, we’ve seen increased engagement and a renewed excitement amongst our staff.”

Learn more about the CUSP at