Conducting post-fall huddles is an important part of the CAPTURE Falls program implemented by the University of Nebraska Medical Center in Omaha. Katherine J. Jones, PT, PhD, associate professor in the Division of Physical Therapy Education, says they are an important part of the learning process because the participants can learn both what is working in the program and what might need more attention.
“The purpose of the post-fall huddle is not to identify who did something wrong and punish them. Rather, the goal is to assess the overall situation, including what happened with that particular patient in that one fall and also what might be learned about the program overall, such as how staff are trained,” Jones say. “We’re looking for ways to help prevent another fall with that one patient, but also how to improve our program so that we can protect other patients as well.”
The concept does run into some practical challenges. Hospitals participating in the CAPTURE Falls program have reported difficulty getting the huddle completed in a timely fashion because it can be hard to get the appropriate staff members together in one place soon after the fall, she notes. This problem is seen most often on nights and weekends when some desired members of the post-fall huddle, such a physical therapist, may not be available.
One way around that problem is to conduct the post-fall huddle immediately with the team members who are available and then seek input from others afterward, she says. That way, the patient can benefit from any care improvements that are recognized in the huddle without having to wait until everyone is available.
Hospitals also have reported that attaching huddle documentation to the fall event report is useful in ensuring that the huddle team’s observations about possible improvements are carried out.