Fall Prevention Case Study

Fall prevention and management is integral to the care process. Managing the risk of falling requires identifying factors that contribute to falls. The goal of the following policy and procedures would be to encourage each resident’s independence by removing the risk of falls where possible and reducing both the incidence of falls and the injuries that may accompany falls.

As a nurse we want to ensure that our patients receive a high quality of care. Patients should feel safe and satisfied while hospitalized. Many hospitals are continually looking for answers and implementation to significantly reduce the inpatient fall incidents. According to Bechdel et al (2014), the top priority of health care organizations nationwide is to reduce and eliminate falls within the clinical care settings. One of the serious problems in acute care hospital is the patient’s fall. The unfamiliar environment, acute and co-morbid illnesses, prolonged bedrest, polypharmacy, and the placement of tubes and catheters are common challenges that place patients at risk of falling. Most of the falls that I have encountered while working involves

The purpose of this research paper was to examine the latest research and evidence-based practices related to inpatient falls. Falls among the elderly within a hospital setting has increased within the last decade. Inpatient falls have become the second leading cause of death, causing longer hospital stays and indirect costs for the hospital. The research reviewed multiple studies, which discussed the causes of inpatient falls. A few causes included nurses and staff not knowledgeable of current hospital practices, lack of individualized plan of care, and lack of training related to falls. The findings assisted the writer to revise the current fall policy and procedure for Arrowhead Regional Medical Center (ARMC). A fall reduction program

The Center for Disease Control and Prevention (2016) informs us that “health care providers play a major role in fall prevention.” The care of our elders is entrust to all employees, every team member is value and fall prevention is not a concern of only the nursing staff. Therefore, as we embarked on this quality improvement endeavor our entire interdisciplinary team (IDT) met and brainstormed to develop a preventative plan to ensure safety. The fall policy was revised from the standard event reporting guidelines to to a more detailed and specific protocol. This protocol was in addition to the normal assessment, vital signs, mandate paperwork, and the procedures of notify the physician and the responsible party. The new ground rules laid out step by step guidelines. All staff members was informed about our concern with the increase rate of falls, the goal to reduce this number and the role they play in achieving this goal. “Every health care provider should be proactive in evaluating he risk of falls in their elderly patients” (Schimke & Schimke, 2014, p. 228). Therefore, a rallying of the troops is always necessary to assure we are all on board and moving in the same direction. Also, meetings of this nature reduces resistance from the direct caregivers. As well as, provides supports to the supervisors as they enforce and oversee the changes in our procedures. According to Osuji et al,

When asked to compare the policies of the clinical facility to that of the best-practice recommendations the following was revealed. First, the acute-care facility does utilize a fall risk assessment similar to that of the Morse fall scale. The patient is then identified as a fall risk one, two, or three. Based on the score, basic fall interventions are required. For example, a fall risk one requires safety rounds every two hours whereas a fall risk three require hourly safety

Elimination of patient falls is not an easy task otherwise they would have been eliminated by now. Patient falls unfortunately continue to be a challenge and occur within the hospital and nursing home settings at alarming and sometimes deadly rates. The Center for Disease Control estimates that 1,800 older adults living in nursing homes die each year from fall-related injuries. Survivors frequently sustain injuries resulting in permanent disability and reduced quality of life. Annually, a typical nursing home with 100 beds reports 100 to 200 falls and many falls go unreported (CDC, 2015). Falls occur more often in nursing homes because patients are generally weaker, have more chronic illnesses, have difficulty ambulating, memory issues,

The Centers for Medicare and Medicaid Services (CMS) has identified eight adverse conditions, and inpatient injurious falls continues to be the most common adverse condition (as cited in Tzeng, Hu & Yin, 2016). The inpatient falls in the “US hospitals range from 3.3 to 11.5 falls per 1,000 patient days” (as cited in Bouldin et al, 2013, p.13). Roughly 25% of patients are injured when they fall (Bouldin et al, 2013). Since 2005, the USA’s National Patient Safety Goal listed fall prevention as a goal (Bennett, Ockerby, Stinson, Willcocks, & Chalmers, 2014). Since 2008, hospitals no longer receive payments from CMS for health care cost connected to inpatient falls (Bouldin et al, 2013). CMS views inpatient injurious falls as injuries that should never occur (Bouldin et al., 2013). There is no doubt that quality improvement must continue to address inpatient injurious falls. Preventing falls and implementing interventions to lower the rates of falls is a major concern for hospitals and must be included in any quality improvement measure.

Intervening falls can reduce the financial burdens attributed to patient falls in hospitals and other healthcare settings are among the most serious risk management issues facing the healthcare industry.

The purpose and scope of the “RNAO Falls Prevention CPG” are: “To increase all nurses’ confidence, knowledge, skills and abilities in the identification of adults within health care facilities at risk of falling and to define interventions for the prevention of falling. It does not include interventions for prevention of falls and fall injuries in older adults living in community settings. The guideline has relevance to areas of clinical practice including acute care and long-term care,

Method: The study question investigated was; what impact will individualized fall-prevention education, supported by training and feedback for staff reduce have on the number of falls during hospital stays? The study was a pragmatic study of patients admitted to one of 8 rehabilitation units in general hospitals that were over sixty years old, with a projected hospital stay of at least three days, and had basic cognitive functioning. 3,606 patients admitted were admitted to the eight units during the study period, with 1,983 in the control group and 1623 in the intervention group. The pragmatic nature of the study is a strength given the nature of the intervention. However, the investigators do not explain the logic of limiting the study to patients over age 60, with a length of stay of at least three days, and this restricts the extrapolation of the results to these groups.

Falls in a health care setting are costly to the patient, the health care facility and may affect the reimbursement that insurance gives to hospitals, yet they are preventable. Falls can be minor with just a few bumps and bruises or they can be major which can result in death. Not only are falls harmful to the patient but there is a lot of money and time that gets added up after a fall occurs *** There are many factors as to why a fall could take place, but being aware of the risk that a patient is a fall risk from the beginning can help avoid a fall from ever occurring. Accurately identifying a patient as a fall risk and communicating to other staff within 24 hours of admission is key to help in the prevention of falls.

Falls are the leading cause of medical complications in health care facilities in the United States. Statistics from The Joint Commission shows that hundreds of thousands of patients fall in hospitals every year, with 30-50% of those falls resulting in injury (“Preventing falls and fall-related injuries,” 2015). Furthermore, the consequences of falls are that injured patients will require longer hospital stay leading to an increase in healthcare costs (“Preventing falls and fall-related injuries,” 2015). To prevent falls, health care facilities have implemented evidence-based intervention strategies such as fall risk assessment tools and faster call light response time.

Hi Lacey, I agree that a Fall Prevention policy is important in all units in the hospital. I used to work in a Med-Surg floor and the unit I used to work in is competent in following this policy. I remember how everyone worked as a team in making sure the Fall Prevention policy was carried out in a timely manner. Examples that I can recall are: call lights worked and were within reach, low-boy beds with bilateral floor pads were ordered from Hill-Rom as soon as a patient is considered a fall risk, bracelets and doors were used as labels, and reminders to use the call light were placed in ceilings. Most of our fall risk patients in that Med-Surg unit were or elderly patients and post-surgical patients. Additionally, we also considered patients

If patient safety is the most important issue in Health Care facilities then how come hospital inpatient falls continue to be the most reported of all accidental falls (Tzeng & Yin, 2009)? Throughout the years, hospitals continue to make changes to decrease the risk of accidents and increase the quality of patient safety. With research studies and improvements made, patient falls still hold the largest portion of reported incidents in hospitals (Tzeng, & Yin, 2008). According to Tzeng & Yin (2008), “fall prevention programs apparently do not effectively reduce inpatient fall rates because of human factors and ergonomics in a hospital environment (p.179, para. 2). The two studies reviewed in this paper were performed with the hopes of

To date there has been no cure for preventing patient falls. This is a difficult task and perhaps one of the most frustrating issues facing management and direct care providers due to constant changes in patients, personnel, and environment. This presentation is going to tell you the story of how our medicine unit strategically evaluated falls data through the past three years and implemented 10 interventions resulting in 7 sustained months well below the NDNQI mean for falls per 1000 patient days after a jagged course. This journey began through the use of post falls huddles tools. The staff conducted post falls huddles provided direction for determining an intervention to employ to prevent further