Patient Safety And Quality Improvement Statement And Chosen Cause That Will Drive Improvement

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,

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

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.

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

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

(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)

Many of these inpatient falls can be prevented when following the proper fall prevention measures. Not only does patient safety make preventing falls a priority but the financial impact these falls have on an institution make it a priority as well.

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.”

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,

As the United States population is advancing in age, the amount of patient falls and medical costs are estimated to increase. Approximately 700,000 patients fall per year in the hospital, which one-third of those falls could have been prevented (AHRQ, 2012). Prolonged hospital stays related to fall injuries is very costly. In 2013, a total of $34 billion dollars was paid due to falls by patients and insurance companies (CDC, 2015). Examples of injuries that can occur as a result of falls are fractures, lacerations, or internal bleeding (AHRQ, 2012). Studies also show

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.

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