Capstone Hospital Falls Case Study

During hospitalizations, falls are amongst the highest preventable consistent adverse events. Preventing such undesirable events, enhances patient overall experience, as well as increased trust in the health care professional team (Fragata, 2011). The importance of fall prevention lies with the many serious unfavorable health outcomes it can pose on the patient. Falls have the potential increase length of hospital stay, limit mobility, independence, but can ultimately lead to health deterioration, including death. Worldwide, falls are the second leading cause of accidental death. In addition to the life-threatening health and safety risks falls have to the patient, it also as a financial impact,

The Center for Disease Control (CDC) reported that more than one third of adults 65 and older fall each year. Half of the elderly people, who fall, do so repeatedly. Aside from the health problems related to falls, nearly $20 billion of direct medical costs are associated with fatal and non-fatal falls (Larson & Bergmann, 2008).

Falls are a great health concern for hospitalized patients since it has been ranked the

The Cochrane Library search with the MeSH heading accidental falls yielded 7694 articles. To further narrow the search, the MeSH headings bed alarm AND hourly rounding were added. This yielded six articles, one of which was applicable to this study.

If there is a fall with injury, the manager has the ability to go back and check how long the call light was on prior to a fall. However, this information is not used to prevent and emphasize the relationship between the length of time a call light is on and the rate of fall. Most nurses and patient care technicians are not aware that the manager can back-track the call light and find out this information. To measure the rate of falls to the length of time a call light is answered, the nurse working on the project choose the histogram. This illustrates the length of time in the Y axis and the rate of falls in the X axis during the period of study (time frame). The histogram itself will include a control group, average answers, and delay answers to call light. This example was imported and modified from a previous study done comparing the numbers of call lights and nursing rounds by (Meade et al. 2006).

Healthcare organizations rely on incident reports for counting the frequency of falls and collecting fall-related data (Quigley, Neily, Watson, Wright, & Strobel, 2017). When a fall occurs in a healthcare organization, an incident report is completed to record the occurrence and circumstances surrounding a fall (Quigley, Neily, Watson, Wright, & Strobel, 2017). The definition of a fall is a loss of upright position (Quigley, Neily, Watson, Wright, & Strobel, 2017). A sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor, ground, or on an object (Quigley, Neily, Watson, Wright, & Strobel, 2017). When a fall occurs in a healthcare organization, an incident report is completed to record the occurrence and circumstances surrounding a fall (Quigley, Neily, Watson, Wright, & Strobel, 2017). The data might include time of day, location, activity, vital signs, and incontinence (Quigley, Neily, Watson, Wright, & Strobel, 2017). From the analysis of the data, one can determine the type of fall, such as accidental, anticipated physiological, and unanticipated physiological fall (Quigley, Neily, Watson, Wright, & Strobel, 2017). Along with the severity of the injury, minor, moderate, major, or severe, as well as to identify overall patterns and trends surrounding fall occurrence (Quigley,

Jillian Clark, Jennifer Cowan, Melissa Stultz, Haleigh Svoboda, Ashlene Sharma, Stephon Lampkins, Basil Singh, Shardae Williams, Donshaneice Brown, Eli Polinard, and Latisha Griffin

In USA, one in three adults over age 65 suffer fall while 20% to 30% experience moderate to severe injuries (Centers for Disease Control and Prevention, 2010). In 2010, the cost of falls among elderly people for US health care system was over $30 billion (Centers for Disease Control and Prevention, 2010). Over the last few decades the rate of fall related deaths in USA has sharply been escalating. Many older adults have developed the fear of falling, limiting their social activity and forcing them to live in fear. Some adults suffer lacerations, fracture and trauma during fall, deteriorating their quality of life.

“In the United Sates, unintentional falls are the most common cause of nonfatal injuries for people older than 65 years (Hughes, 2008).” This illustrates a problem that requires addressing. “Rates of falls vary across hospitals and units however, the highest rates are found in neuroscience (6.12-8.83/1000 patient days) and medical (3.48-6.12 falls/1000 patient days) units” (Mion, 2014). Older adults are usually those most affected and their falls are

I interviewed James Alviar RN, the Coordinator of Risk Management at my current place of employment the Queen's Medical Center West Oahu. I asked him if there were any current risk management issues at our facility that we could discuss, but he said all current issues were confidential and he could not divulge any information to me. Instead, James pointed me in the generic direction of hospital falls that is a nationwide risk management issue and also pertains to us at Queens Medical Center. This paper will be discussing risk management's role, what falls are, how falls are addressed, how risk

Falls are considered a leading cause of mortality and injury among older adults and majority of the falls occurs while hospitalized. One would think being in the hospital would be one of the safest places for older adults as far as fall prevention is concern due to the fact that hospitals provide staffing around the clock for patients but more and more falls have been occurring in the hospital especially in the older adult population. Fall is an unintended descent to the ground. It raises public and family care liability; it also decreases patient’s functioning because it causes pain and suffering, and increases medical costs (Saverino et al, 2015). The Center for Disease Control

Fall risk assessments tools, which help to identify those patients at risk of falling, play a vital role in reducing the number of falls. The basis for this assessment is that if patients at high fall risk can be

A fall is a lethal event that results from an amalgamation of both intrinsic and extrinsic factors which predispose an elderly person to the incident (Naqvi et al 2009). The frequency of hospital admission due to falls for older people in Australia, Canada, UK and Northern Ireland range from 1.6 to 3.0 per 10 000 population (WHO 2012). The prevalence of senior citizen’s falls in acute care settings varies widely and the danger of falling rises with escalating age or frailty. Falls of hospitalized older adults are one of the major patient safety issues in terms of morbidity, mortality, and decreased socialization

Risk factors for falls are categorized by intrinsic or extrinsic (Tzeng, & Yin, 2009). According to Tzeng and Yin (2008), intrinsic factors, referring to the patient themselves, are related to their health status and possibly associated with age-related changes: previous falls, reduced vision, unsteady gait, musculoskeletal system deficits, mental status deficits, acute illness, and chronic illness. Extrinsic factors are involved in the patient’s environment, including medications, lack of support equipment, furniture, bathroom designs, small patient rooms, poor lighting, and improper use of and inadequate assistive devices. Tzeng & Yin (2008; 2009) focused on the extrinsic risk factors for the basis of their studies.

Internet Citation: Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3h.html