Leadership Experiences And Complexity Theory

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.

This work has significance because staff and patient education can help prevent falls. Specific interventions decrease falls. Nurses have a responsibility to their patients and their facility to be competent and confident in their abilities to do all that they can to prevent falls. Facilities have the responsibility to provide the tools and the training that is required to carry out fall prevention

Patients are medicated, in an unknown environment, attached to lines, drains, and physiologically impaired in some manner. They are at a very high risk for falling. The American Hospital Association explains how participating hospitals have reduced falls by 27% by using the bundles and toolkits from Hospital Engagement Network (AHA HEN), this process requires the interdisciplinary team involvement. Each has their own role, nursing plays a critical role in fall prevention, they are with the patient for 12hours in a hospital setting and have direct care with assessing, creating a care plan, implementation of interventions, and evaluation. They can report any concerns or data to the

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

The nursing process has been improved along the way, from Orlando’s original four step process in the late 1950’s, then, a separate step of a nursing diagnosis was added. As to the American Nurses Association Scope and Practice (2nd Edition, 2010), there was another important step of expected outcomes to identify patient goals. So, as the nursing process has been re-evaluated and improved the patient is re-evaluated and improved by the improved nursing process-problem solver. My fall prevention project has revealed to me and my readers there are vast numbers of risk factors that are involved in falls including medications, nutrition, cultures (beliefs), mental status and a history of falls. The nursing process has been and will always be used

Brittany Nix- This writer believes a key point or concern for health care professionals is how to keep the middle age group safe while maintaining privacy and independence. In comparing the first research to the current, data findings revealed the incidence of falls in middle-aged inpatients were similar to older inpatients. Far too often this writer feels the nursing profession stereotypes the older population while overlooking the risk in middle aged adults. This writer believes this research challenges nursing professionals to implement individualized fall prevention for patients, regardless of

Patient falls is one of the commonest events within the healthcare facilities that affect the safety of the patients. Preventing falls among patients requires various methods. Recognition, evaluation, and preventing of patient falls are great challenges for healthcare workers in providing a safe environment in any healthcare setting. Hospitals have come together to understand the contributing factors of falls, and to decrease their occurrence and resulting injuries or death. Risk of falls among patients is considered as a safety indicator in healthcare institutions due to this. Falls and related injuries have consistently been associated with the quality of nursing care and are included as a nursing-quality indicator

The lack of proper education on identification of falls risk and falls prevention measures impact patient falls. Staff turnover and the use of temporary staff contribute to miscommunication or lack of communication on processes such as fall prevention measures. Experience levels vary on any given unit. Educational needs assessments should be routine and include temporary and new staff. Authors Manojlovich, Sidani, Covell, and Antonakos (2011) define nurse dose as “the level of nurses required to provide patient

Patient falls have been a long debated healthcare issue throughout time and measured as a nursing sensitive issue. The National Quality Forum (NQF) has endorsed patient falls with an injury with the steward of the American Nurses Association (NFQ: Quality Positioning Systems, 2014). All patient falls are documented per 1,000 patient days via the measurement description (NQF: Quality Positioning Systems, 2014). The target population that accounts for the total number of patient falls is in the medical-surgical, step-down, critical care, critical access, surgical, medical and adult rehabilitation units (NQF: Quality Positioning Systems, 2014). The Center for Control and Disease (CDC) has reported that every seventeen seconds, an elderly patient will have a fall in a hospital (Hill & Fauerbach, 2014). The majority of falls are associated with patients ambulating from a bed, chair, or toilet without the proper assistance (Shorr, Chandler, Mion, Waters Liu Daniels, et al., 2012). There is a new regulation published by the Center for Medicaid Services. It states that injuries acquired through a fall in an organization will be held responsible for those medical costs (Hill & Fauerbach, 2014). In fact, in 2010, there was approximately $30B in hospital costs related to patient falls (Hill & Fauerbach, 2014). With the increasing number of patient falls in acute care settings and the change of healthcare coverage, does the use of bed alarms reduce the risk of falls of

Problem Significance Fall is a nursing sensitive issue that require more attention from all healthcare professionals. As patients’ safety is one of many responsibilities of nurses, it is crucial for nurses to address issue related to fall injuries. The goal of nursing practice is to promote health and to alleviate pain and

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.

A patient fall is one of the unit-based nursing-sensitive indicators in 6 East, a 22-bed adult unit in a 594-bed tertiary hospital in downtown Charleston, SC. The majority of the patients’ population in this unit is pre and post liver transplant, renal transplant, pancreas transplant, nephrology, urology, and general medicine. The fall rates in 6 East were 6.09 total falls per 1,000 patient days during the 1st quarter of 2015 and 7.56 on the 2nd quarter. These statistics were tremendously beyond the 3.28 total falls per 1,000 patient days of the National Database of Nursing Quality Indicators (NDNQI) benchmark of hospitals of > 500 beds. The significant fall rates in the unit accounted about 35% of the total falls on the hospital during the first half of the year. Although the hospital has a fall prevention program and policy, there is a knowledge gap among nurses and patient care technicians (PCT) regarding fall prevention due to lack of proper education reinforcement. This has led to an increase of staff non-compliance with the policy and fall rates in the unit. Furthermore, with the unit having high staff turnover rates, the newly hired staff members are not getting a proper staff education on fall prevention. Therefore, these newly hired staff members are unable to implement the fall prevention strategies and procedures efficiently.

Another feasible solution would be an initiation of bedside shift reports that move along with the patient to alert other staff of concerns of falling if the patient is at risk (Miake-Lye et al., 2013). It is also imperative that the leaders consider providing adequate lighting in places that the patients use as well as a scheduled rounding protocol for patients who require frequent toileting (Grol et al., 2013). Lastly, attention will also be drawn to the importance of leaders of healthcare organizations in promoting an organizational culture that values the safety of their patients. The support of the leaders is particularly crucial because, besides the establishment of goals and objectives geared towards achieving zero falls, they provide the resources and support needed for the program and provide good examples for other staff members (Grol et al., 2013). Also, they help to monitor if the staff members are adhering to the implemented care protocols (Grol et al.,

Patients are our top priority here at Saint Luke’s Memorial Hospital in which it is important to always identify means of ensuring patients’ safety. A new initiative that I would like to propose concerning patient safety is fall prevention, as important as hand hygiene and medication administration is we are having issues in this area that needs to be addressed with the utmost attention. As the administrator for Saint Luke’s, I, Lunese Boco, make it my duty to keep all patients safe and out of harm’s way. We pride ourselves on providing the best services here are Saint Luke’s Memorial Hospital therefore it is vital that we implement a patient fall prevention program along with a firm policy concerning patient falls. It is imperative that all patients leave our facility healthier than how they entered because of our excellent service and dedication to each and every patient. All populations in the hospital setting can be affected by a fall from an infant to an elderly adult. There is no universal definition for “fall” in which Joint Commission and others define a “fall” as unintentional unplanned descent with or without assistance of another person to the floor with or without injury (Rowe, 2012). Falls are anticipated or unanticipated due to various risk factors or due to environmental influences. The American Nurses Association determines that in all aspects of physiological or environmental situations and with injury or not a descent to the floor is