Core Measure Sets Are Used For Measure Quality Care Essay

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,

Falls are one of the major patient safety problems that every facility encounter on a day to day basis. An aging patient population, combined with multiple diagnosis and medications are prime contributing factors for patient fall. Other contributing factors are shortage of nursing and auxiliary staff, ineffective work environment and shortage of appropriate equipment. According to the Joint Commission around 30-50 percent of the falls happening in the hospitals have resulted in injury to the patients. Since Joint Commission started keeping records of fall from 1995 to 2012, it has been reported that there were 659 fall related death or permanent disability, which were voluntarily reported as a

Patient falls in hospitals are a critical problem and are used as a standard metric of nursing care quality. According to the Joint Commission, thousands of patients fall in hospitals each year. Approximately 30-50% of falls result in injuries and prolonged hospital stays. Any patient in a hospital is at risk for falling and certain measures should be in place to prevent this. Preventing falls and injuries are not only important for the patient, but also for their families, the hospital, health care team, and insurance companies. It is estimated the average cost of a hospital admission due to a fall is $20,000 and by 2030, an estimated $54 billion will be spent on health care costs due to falls. The purpose of this paper is to explore the risk factors of falls in hospitals and interventions used to combat this problem.

Falls are a big concern for all employees in a hospital setting daily. The worst thing that can happen to a patient while being hospitalized is a fall, or a major fall, that could result in skin damage (i.e. wounds, skin tears, or abrasions), a fracture or break, thus limiting their independence. This student’s goal was to develop a way to educate staff members in ways they can help reduce the number of falls that occur. Developing a sample Fall Risk Prevention Policy as well as a Staff in-service on fall risk and Prevention achieved this goal.

(Tzeng, 2008) It would be ideal to create a fall prevention team that includes current staff who are directly involved in the care of clients. This team would include physicians, former or current staff nurses, assisting personnel, and other healthcare members since they all spend time at the patients’ bedside, and they may have insight into areas of improvement that others may not see. An interdisciplinary effort would be an overall better approach when dealing with precautions that would affect the facility’s policy and procedure changed in the facility. (Hughes, 2007) All of the members input about healthcare improvement may be highly constructive and would greatly benefit safety goals. The Joint Commission emphasizes that a better physical design of facilities may also lead to improved healthcare outcomes such as fewer patient falls. (Joint Commission, 2007)

Capan, K., & Lynch, B. (2007). Reports from the field: patient safety. a hospital fall assessment and intervention project. Journal of Clinical Outcomes Management: JCOM, 14(3), 155-160.

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).

Nurses help to ensure patient safety, which includes preventing falls and fall-related injuries (Quigley, Neily, Watson, Wright, & Strobel, 2017). The general population is at risk for falls and fall-related injuries, more specifically the elderly, 65 and over (Quigley, Neily, Watson, Wright, & Strobel, 2017). Patient falls are one of the top events for hospitals and long-term care facilities due to loss of physical function or cognition (Quigley, Neily, Watson, Wright, & Strobel, 2017). Fall-related injuries are a serious health issue for the elderly population (Quigley, Neily, Watson, Wright, & Strobel, 2017). Nurses make a major contribution to patient safety by assessing fall risk and designing patient-specific fall prevention

Quality improvement is referred to as “the use of data to monitor the outcomes for care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care” (Sherwood & Barnsteiner, 2012). Data is used as the reflection of quality care that is provided by nurses and presents whether or not improvement is needed. In order for nurses to be mindful of the care that they give, they must be taught a systematic process of defining problems, identifying possible causes of those problems, and methods for trying out new solutions to prevent those problems (Sherwood & Barnsteiner, 2012). Currently, quality improvement measures are being utilized throughout hospitals to reduce the risk of patient falls and fall injuries.

At Brigham and Woman Hospital, this fall prevention program has been instituted throughout the facility. The protocol requires all patients to be screened for fall risk factors upon their admission to the hospital. Upon admission, nurses must conduct a throughout medical assessment, and use the Morse Fall Scale to assess patients mobility, muscle strength, gait, vision of patients because those conditions can put patients at increase risk for falls. At the end of each assessment, a number is provided to each patient determining the degree of fall and documented in the patient chart. For example, a patient might be a low risk for fall while another might at high risk for fall. In addition, the nurse must create a plan of care and

Each year, one out of three elderly people fall (U.S. Centers for Disease Control and Prevention [CDC], 2015). The CDC (2015) also reports that once an individual has fallen, the chance that they will fall again doubles. Falls also contribute to an increase in direct medical costs. The CDC (2015) states, “Direct medical costs for fall injuries are thirty-four billion dollars annually. Hospital costs account for two-thirds of the total.” The amount of elderly people who fall each year along with the economic costs that result from falls indicates that preventing patient falls remains an important goal for healthcare workers including nurses. Nurses can use the nursing process—assessment, diagnosis, planning, intervention, and evaluation—to prevent patient falls and meet the fall prevention standards set by various regulating bodies.

Minor (2009) explains the Memorial Hermann Texas Medical Center (MH-TMC) fall reduction committee reviewed the historical data related to fall within their facility and compared their data with the national data. Therefore, indicators used were patient fall rates, also the outcome indicators used were patient fall rates. Thereby, reviewed were the current data, recommendations, and current practice. Also, the utilization of the National Database of Nursing Quality Indicators (NDNQI) was completed for the external benchmarks. Also, completion of the national comparison of patient falls in other facilities. Also, internal benchmarks were utilized within the organization for the comparison different population risks, patient acuity levels,

This project is part of an existing Quality Improvement Project by the organization on falls prevention, the most important aspect of a falls prevention initiative is using a standardized fall risk assessment (such as the BRIGGS Healthcare Falls Risk Assessment) to support the Quality Improvement Project. Quality Improvement projects are vital to any organization; they are data-driven, usually involve human participation. Also, it is a systematic approach, data-guided activities designed to bring about improvement in health delivery system. The fundamental obligation of health care providers and stakeholders are improving the quality of care of patients (Zaccagnini & White, 2011).

Kalisch, B. J., Tschannen, D., & Lee, K. H. (2012). Missed nursing care, staffing, and patient falls. Journal of Nursing Care Quality:, 27(1), 6-12. doi: 10.1097/NCQ.0b013e318225aa23

A fall can make wide spread consequences on the health service or can be affected seriously by the increased health care utilization. Among the fallers approximately 30% of falls result in physical injury leading to extensive hospitalization with significant hospital expenses (Tzeng & Yin 2010). Preventive care phases can support health services to regulate the spare expenditure to a greater extend. A fall in hospital consequently affects the nursing staff, which lead to impaired job satisfaction, additional work load and startling time consume. As the front line of care, nurses can prevent falls and reduce fall injury rates in acute care unit with available resources (Dykes et al. 2013). This literature review aims to assess the efficiency of planned interventions to reduce the incidence of falls in acute medical units. The discussions of the main findings of the review as well as the recommendations for further research are revealed to conclude this study.