Patient Falls 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,

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.

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.

Problem: Patient falls have long been a common and serious problem in hospitals across the nation, causing

For the most part, hospitals are places where one comes for healing and it is place where our clients should feel safe and away from harm. Nurses have an important role as a patient advocate and are to provide all clients with safe, compassionate, and quality care at all times. Nonetheless, the hospital can also be a dangerous place for inpatients. It is a foreign environment to clients and there may be alterations in their medical condition in regards to their physical and/or mental status. With this said, there is a need to improve upon how we care for our clients, especially those who are at most risk for various incidents.

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.

In the healthcare system, Core Measure sets are used to measure quality care. It consists of pneumonia, heart attack, immunizations, emergency department, sepsis, for infection prevention, and others. Evidence-based treatments are used to prevent occurrences using structures, processes, and outcomes. In nursing, they have adopted a similar method of performance measures, known as nursing-sensitive indicators. It includes falls, and this indicator is implemented in each unit of the hospital and managed by the manager and educator along with others like CAUTI and CALBSI. According to the American Hospital Association article (2015) “Falls with Injury,” Patient falls-an unplanned descent to the floor with or without injury to the patient affects between 700,000 and 1,000,000 patients each year.”

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

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,

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.

Quality management is essential to the success of the quality improvement of the health care industry. “Management uses management and planning tools to organize the decision making process and create a hierarchy when faced with competing priorities “( Ransom, et al., 2008). Quality measures should have these goals: effective, safe, efficient, patient-centered, equitable, and timely care (Quality Measures, Center for Medicare & Medicaid Services, 2011).

Patient safety is one of the nation's most imperative health care issues. A 1999 article by the Institute of Medicine estimates that 44,000 to 98,000 people die in U.S. hospitals each year as the result of lack of in patient safety regulations. Inhibiting falls among patients and residents in acute and long term care healthcare settings requires a multifaceted method, and the recognition, evaluation and prevention of patient or resident falls are significant challenges for all who seek to provide a safe environment in any healthcare setting. Yearly, about 30% of the persons of 65 years and older falls at least once and 15% fall at least twice. Patient falls are some of the most common occurrences reported in hospitals and are a leading

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.

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