Patient Safety And Quality In Health Case Study

A patient who is admitted to a facility may be alert, oriented, and independent in ambulation. Add on intravenous (IV) tubing attached to a pole, a telemetry monitor, a foley catheter, and new medications for the patient. This patient now has fall risk factors. The purpose of this paper is to describe and evaluate change in preventing falls in the hospital setting.

Patient Safety and Quality Improvement Act (PSQIA) was signed into law on July 29, 2005, published on November 21, 2008 and became effective on January 19, 2009 (U.S. Department of Health & Human Services, n.d). PSQIA catalyzes sharing of healthcare data, information and patient safety practices between health care organizations by creating Patient Safety Organizations (PSO). Providers can report or share information related to patient safety events with PSO without the fears of liability, because “ PSQIA provides federal privilege and confidentiality protections for patient safety information, called patient safety work product” (USDHMS, n.d ). This means protected information cannot be introduced in any federal, state, local, or tribal civil,

Fall-Risk Assessment/Assessment: Comprehensive evaluation guide form that reviews all of the resident’s risks for falling including history of falls, medications, and mental status.

In the United States alone there are 98,000 deaths per year caused by low quality health care (Ignatavicius & Workman, 2013, pg. 2). This statistic is disturbing because the errors that resulted in death were errors that were preventable. The intent of this chapter is to bring awareness to health care providers that are able to make a change in the quality of health care. In current practice patients are subjected to medication errors, preventable hospitalizations, premature death, and poor care provided due to racial, ethical, or low-income factors.

Current literature has exposed many risk factors for falls. There are both intrinsic risk factors and extrinsic risk factors. Intrinsic risk factors include changes that come with age, such as gait issues, urinary incontinence, and fear of falling. Extrinsic risk factors include those that are related to the physical environment such as improper use of assistive devices and poor floor surfaces. No matter the type of risk factor, it is crucial to conduct a risk assessment when trying to prevent falls from occurring. Pearson and Coburn (2011) found that identifying risk factor for falls will help identify appropriate prevention strategies. Fall risk assessments help determine Talk about

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.

The widespread falls among the geriatric population reduce their quality of life and take away their functional independence. Lee et al (2013) state that falls leads to the rise in mortality rates and morbidity complications such as fractures and disabilities,1 out of 3 elderly persons in a community setting falls in a year. About 87% of all fractures in the elderly are due to falls. Several of the risk factors that are associated with falls are visual impairments, cognitive impairments, and health-related problems: arthritis, orthostatic, back pains, lack of balance-weakening muscles, previous falls, polypharmacy or psychoactive drugs (Lee et al, 2013).

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

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

A falls risk assessment is recommended as part of a routine medical examination for all older adults as well as for individuals with medical conditions that effect gait and balance. If you have a history of falls or or if you have been diagnosed with osteoporosis or fractures related to osteoporosis, it is imperative to speak to your healthcare provider about your personal risks for falling and about the fall prevention steps you should take to protect your bones.

I interviewed James Alviar RN, the Coordinator of Risk Management at my current place of employment the Queen's Medical Center West Oahu. I asked him if there were any current risk management issues at our facility that we could discuss, but he said all current issues were confidential and he could not divulge any information to me. Instead, James pointed me in the generic direction of hospital falls that is a nationwide risk management issue and also pertains to us at Queens Medical Center. This paper will be discussing risk management's role, what falls are, how falls are addressed, how risk

Fall risk assessments tools, which help to identify those patients at risk of falling, play a vital role in reducing the number of falls. The basis for this assessment is that if patients at high fall risk can be

“For example, these nurses developed a standardized manner with consistency and coherence to perform fall assessment and documentation as well as collect the patient information regarding fall prevention” (Breimier, Halfens, & Lohrmann, 2015, p. 8).Participants identified the Falls CPG included useful recommendations, were helpful in decision making, for each field (Breimier, Halfens, & Lohrmann,

Risk factors for falls are categorized by intrinsic or extrinsic (Tzeng, & Yin, 2009). According to Tzeng and Yin (2008), intrinsic factors, referring to the patient themselves, are related to their health status and possibly associated with age-related changes: previous falls, reduced vision, unsteady gait, musculoskeletal system deficits, mental status deficits, acute illness, and chronic illness. Extrinsic factors are involved in the patient’s environment, including medications, lack of support equipment, furniture, bathroom designs, small patient rooms, poor lighting, and improper use of and inadequate assistive devices. Tzeng & Yin (2008; 2009) focused on the extrinsic risk factors for the basis of their studies.

As previously stated, falls account significantly for injuries witnessed in hospitalized patients. Falls are attributable to risks which can either be intrinsic or extrinsic. Intrinsic factors predisposing patient to falls relates to their physical state or their overall level of wellbeing (Miake-Lye et al., 2013). For instance, issues such as their age, gender, balance, ailments such as arthritis affecting their level of incapability, etc. Extrinsic factors relate to the patient's environment such as the lighting levels, the slipperiness of hospital floors and other contributory factors (Miake-Lye et al., 2013). The bottom line, however, is that most of these risk factors can be assessed, and appropriate measures taken to prevent most of these