For this assessment you will develop an online resource repository or tool kit of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan to understand or implement to ensure the success of the plan.
For this assessment build on the work done in your first three assessment and create an online tool kit or resource repository that will help the audience of your in-service understand the research behind your safety improvement plan and put the plan into action.
Preparation. Google site is recommended for this assessment: Links to google site:
G Suite learning center. (n.d.). Get started with sites: https://gsuite.google.com/learning-center/products/sites/get-started/#!/
instructions: using google site assemble an online resource took kit containing at least 12 annotated resources that you consider critical to the success of your safety improvement plan. Choose 4 catagories and each have three resources.
The Benefits of Fall Protocols
Developing a Healthcare Perspective
Assessment 1: Enhancing Quality and Safety
Various healthcare settings are faced with safety and quality issues. One of the major issues is falls, especially with the older generation. Hospitals, nursing homes, and assisted living facilities have a high number of falls daily and most of them are with the elderly. One study found that “Falls are the sixth most common cause of death among the elderly and account for 70% of accidental deaths among those aged 75 years or more” (Alves, 2017).
Factors that Lead to Fall Risk
However, there are several factors that increase the risk of falls within the elder generation. Stroke victims, cardiac patients, respiratory problems, orthopedic and cardiovascular patients. The older generation who have cancer has a big increase in fall risk because of the increasing drugs. Cancer patients are typically on psychotropic drugs like Antidepressants and Opioids that have side effects of dizziness and drowsiness, which causes the elderly to be unsteady on their feet. Most sleep aids cause lightheadedness, dizziness, disorientation, and confusion, especially in the elderly (Turner, 2017)
Cardiac patients who are on a diuretic go to the bathroom frequently during the night. This increases the patient’s risk of falling when they have the urgency to go to the bathroom, especially if there is no night light on. Usually by the age of 65 most elders have vision loss which impairs their night vision. Yet, another fall risk. Aside from the different diagnoses’ elderly lose their muscle strength, have changes in their gait and posture, which are often the reason elderly stumble and fall. They become more and more unsteady on their feet. (Alves, 2017). Other contributing factors for falls are cognitive impairment, over- estimating one’s ability, impulsive behaviors, and sensory deficits.
Yet, a large increase of falls is associated with unassisted falls in healthcare settings. The failure of staff not completing a fall assessment on elderly patients to determine their ambulation needs, which increases the risk of falling. Undefining who needs to be on a fall protocol, and the lack of putting one in place increases the risk. Cluttered patient’s rooms, no call light, and lack of personal items within reach of the patient increases the risk of falling. Unassisted falls, and assisted falls without the use of a gait belt puts client’s at a high risk for falling (Venema, 2019).
Although there are many factors that increase the risk of falling in healthcare settings, we as professionals have to find a resolution. Healthcare professionals must ensure that they utilize evidence-based practices in reducing falls, especially with the elderly’s who are at a higher risk for permanent debilitating injuries and fatality. It is equally important, staff acquires new knowledge, skills, and attitudes in the following six QSEN competencies: Patient-centered care, teamwork and collaboration, evidence-based practice, quality improvements, safety, and informatics (Falls, E., & Hensel, D. , 2012).
The first step in preventing falls is to determine who is at risk for falling, and how high is their risk for falling. One resolution to preventing falls in healthcare settings is to implement a mental status exam, and the fall risk assessment tools, which is a crucial element in determining who is at risk for falling (Yasan, 2020).
In addition, there should be a Fall prevention plan in place, especially for the elderly. The patient should be involved in their safety fall plan. First, the patient should be aware that they are a fall risk. Second, they should be given strategies and safety goals, and they should be educated on those goals and expected outcomes. For an example: you actively engage the patient. You ask the patient what their concerns are about falling. You explain to the patient that due to their illness and or the medication they are taking may cause them to become weaker than normal and off balance, therefore, they may need assistance ambulating. So, you instruct the patient to use the call bell to notify the nurse when they need assistance to the bathroom. Instruct the patient to always call the nurse before they get out of bed. Discuss the benefits and reward for no falls during their recovery (Rochon, R., & Salazar, L., 2019).
In addition to the fall risk assessment, there are fall risk alerts like, Bed and Chair alarms that aid in fall prevention. Modification of environment or equipment, like moving chairs and tables out of the way. Keeping oxygen machines, and other equipment in the patient’s room and corridors out of the walkway. Keeping a clear entryway free of clutter minimizes falls. Staff assistance with toileting and transfers reduces falls, specifically when using a gait belt. Gait belts also reduce the severity of the injuries sustained when falling. Placing the patient on a toileting regimen or having a commode next to their bed decreases falls. Wearing a fall risk identification band notifies the staff that the patient is a fall risk, which increases staff surveillance.
However, Nurses can ensure the safety of the patient by initially doing a fall assessment. Next, place the patient closest to the nurse’s station for observation and surveillance. Patients should be oriented to their environment. Nurses should ensure that the call light, and the patient’s personal items are always in reach. They should have the patient demonstrate how to use the call bell and instruct patients to always rise slowly. Nurses should instruct patients on always wearing non-slip socks or slippers when ambulating, and to keep them at bedside. Signs should be visual in rooms “Fall Risk”. Lights should be adjusted for activities and night lights should be available too. Nurses are to ensure that hospital bed brakes are locked and in low position, and bedrails are up to prevent falls. Patient’s should be instructed to use their canes, walkers, any assistive devices recommended by Physical therapy to assist them with ambulation and transfers. Nurses should provide hourly rounds and delegate the task to aides to assist in hourly rounds. Nurse should incorporate measures that will reduce falls, like encouraging exercise and physical activity, monitoring patient’s medications, and providing a hazardous free environment (Weaver D., 2008). These are the many strategies that nurses can enforce to assist in fall prevention for enhancing quality and safety and reduce cost.
Falls can be a detrimental experience for the elderly, because it may lead to the elder being incapacitated, affected with serious injuries, and or fatality. When one loses their autonomy and independence or must be institutionalized the social cost can be enormous (Alves, 2017). “The Centers for Disease Control and Prevention (CDC) identified falls as the leading cause of injury-related death in adults over age of 65 with costs totaling $34 billion (78% paid by Medicare)” (Rochon, 2019).
The stakeholders are the patients, the physicians, employers, staff, insurance companies, and the government (Medicaid). To drive quality and safety enhancements nurses need to coordinate care with the patients to get them to recognize when they are a fall risk and to be a part of their safety prevention plan that is incorporated into their care plan. The physicians are stakeholders who need to participate in the care plan and possibly modify orders to accommodate the fall prevention plan. The employers and staff role are able to keep the hospital environment safe and free from clutter and keep patients safe. Hospital acquired conditions, like falls or falls with injuries do not qualify for reimbursement from Medicare or Medicaid (Rochon, 2019). The cost could be detrimental to the patients and the hospital.
In conclusion, it is vital that on admission fall risk safety tools are implemented to assess the level of care that the patient needs to improve safety and quality in healthcare settings. Goals should be set with the patient to eliminate falls during their recovery and strategies should be implemented to reduce the risk of falls. Nurses should delegate strategies to staff to prevent falls. The healthcare team and the hospital staff should be made aware of patients who are at high risk for falls, so that they can participate in the fall risk prevention and quality safety assurance of patients. Healthcare Professionals must implement every evidence-based strategy that reduces the risk of falls into practice to improve the quality and safety of every individual patient.
Alves, R. L. (2017). Evaluation of risk factors that contribute to falls among the elderly.
RevistaBrasileira de Geriatria E Gerontologia, 56-66.
Falls, E., & Hensel, D. (2012). Characteristics that perinatal nurse managers desire in new nurse hires. The Journal of Continuing Education in Nursing, 43(4), 182-187.
Rochon, R., & Salazar, L. (2019). Partnering with the Patient to Reduce Falls in a Medical-Surgical Unit. International Journal of Safe Patient Handling & Mobility (SPHM), 9 (4), 135-142.
Turner, J. P. (2017). Factors associated with use of falls risk-increasing drugs among patients of a geriatric oncology out-patient clinic in Australia: a cross -sectional study, 361-368.
Venema, D. M. (2019). Patient and system factors associated with unassisted and injurious falls in hospitals: an observational study. Venema et al. BMC Geriatrics.
Weaver D. (2008). Effective strategies in managing Falls prevention. Nursing & Residential care, 10 (5), 217-222.
Yasan, C., Burton, T., & Tracey, M. (2020). Documentation of falls prevention in a patient centered care plain in a medical ward. Australian Journal of Advanced Nursing, 37 (2), 19-24.
Root-Cause Analysis and Safety Improvement Plan
May , 2020
Unfortunately, fallsarewidespread and a devastatedcomplication of hospital care, especially among the elderly population, which is a threat to patient safety. For many years’ healthcare facilities have experienced numerous patients fall incidents, which are the root causes for serious injuries, long rehabilitation, increase cost, and fatalities. However, in this analysis we will be exploring a root cause analysis as to what are some of the contributing factors to an unassisted and assisted fall in hospital settings.
In this scenario,a 60-year old female diagnosed with CHF and insomnia had an unassisted fall. At 2 am, during rounds the nurse on duty found said patient lying on the floor of the entryway to the bathroom. She was barefooted. The bathroom light was off, the only visibility came from the light in the patient’s room. Her prescription glasses were found in the draw next to her bed. She sustained no injuries. The following day said patient had an assisted fall. She was assisted by a certified nurse’s aide into the shower. Patient slipped and fell upon stepping out of the shower and fractured her right hip.
In both incidents the patient, the staff, and the hospital were affected by the events. The patient sustained an injury that prolonged her stay, which physically debilitated her, and led her into an early retirement and reduction in pay. Hospital associated falls are a financial lost to the hospital organization since Medicare and Medicaid does not pay for hospital prevented injuries.As stated by Tzeng, “Beginning in FY2009, the Centers for Medicare & Medicaid Services (CMS) ended payment for care needed to treat certain preventable inpatient injuries that occur during hospitalization (e.g., fractures, dislocations, intracranial injuries) and often are caused by patient falls” (Tzeng, 2015).
However, as the charge nurse, I investigated the case to determine what happened, what were the contributing factors to each incident and what could have been done to prevent those fall incidents. First, anytime a patient has a diagnosis of CHF and insomnia who is prescribed a diuretic and sleep medication the admitting nurse should perform a fall risk assessment. When one has a co-existing medical condition, it contributes to an increased risk for falls (Chien, 2016). Upon completion of the evaluation aFall risk plan should have been implement. There should be specific goals and strategies in place to reduce the patient’s risk for falling. This plan should be based on patient centeredness. A plan where the patient, nurse, and healthcare team work together in keeping patient safe.
This plan should consist ofPatient wearing a fall risk bracelet, signs in patient room notifying staff that patient is a fall risk. It should be communicated among the patient’s healthcare team that the patient is a high risk for falling. It should be noted in the patient’s electronic medical risk that they are high risk for falls. Next, there should be set goals in place between the nurse and the patient in keeping patient safe. For example, in this scenario the patient’s personal items, call bell, and non-skid socks should have been in reach of the patient at all time to decrease the risk of falling.
However, if the patient would have been aware that she was a fall risk and the call bell was in reach she could have called for assistance to the bathroom. If said patient had on non-skid socks that would have decreased the risk of falling. If her glasses would have been in reach perhaps, she would have been wearing them, which would have enhanced her visibility and decrease the risk of falling.A night light would have been helpful. Considering the patient is on a diuretic, she should have been on a bathroom regimen. Having afall-risk plan in place specified for this individual patient would have reduced the patient’s risk of falling.
After the initial fall, the patient was determined a fall risk and was assigned to staff as an assist. Patient was instructed to use call bell whenever she wanted to get out of bed. Patient called for assistance and the aide assisted her to the shower. Upon exiting the shower, the patient slipped and fell. The aide tried to assist her but her wet body was slippery, and she slipped out of the hands of the aide and fell to the floor fracturing her right hip. This injury could have been prevented with the use of a gait belt. Gait belts assist caregivers in control and alleviateinjuries from falls. It is a way for the caregiver to control the patient’s movement and reduce the risk of falling. Stated by Walker, “In our organization, gait belts are a nurse-driven intervention, and nurses are encouraged to use them when ambulating a patient identified as at risk for falling” (Walker, 2015). Plans must be implemented to reduce the risk of assisted and unassisted falls in healthcare facilities.
Fall Risk Safety Improvement Plan
First, we implement a universal fall prevention plan for all patients. Every patient should be screen for high fall risk on admission by the admitting nurse. Once determined their status as high risk for falling, a fall prevention plan should be implemented by collaborating with the patient and their family to develop a personalized plan for the patient based on their personal contributing risk factors. For example, this patient risk factors would be based on diagnoses and medications administered, it would be noted as an anticipated physiological fall. Empowering patients to be apart of the fall prevention plan is essential (Tzeng, 2015). Nurses should include patient centeredness into their hospital care plans.
There should be a standard protocol in place once a patient is determined they are a physiological fall risk. That protocol should be tailored to the patient’s risk factors. First, patients should be made aware that they are a fall risk and why and what necessary goals and strategies we are putting in place, and their role in keeping them safe from falls. Patient must be instructed to call for assistance when getting out of bed. They should be educated on how to use the call bell. The staff must ensure that all times the call bell, and patient’s personal items, and non-skid footwear are in reach of the patient.The patient should be closest to the nurse’s station. Frequent or hourly rounds should be performed. There should be a night light in patient room and bathroom. They must have a bed and chair safety alarm to notify staff of their attempt to get out of bed without assistance. A bathroom regimen must be implemented when a patient is on a diuretic. An ID fall risk band and signs in patient rooms for staff awareness.Assisted falls should always be managed using a gait belt to minimize falls, and falls sustained with serous injuries. It is imperative that nurses implement evidence-based practices that support effective care, improving patient outcomes, and decreasing patient cost. “Evidence-based practice benefits everyone in healthcare” (Spruce, 2015).
Teamwork is essential in improving patient safety. The patient, their families, the physicians, nurses, and entire hospital staff can aide in improving a fall safety program. Team collaboration improves communication and reduces high risk falls and errors. The Agency for Healthcare, Research, and Quality (AHRQ) can be leveraged to improving a fall safety program. As stated by Barry, “One approach supported by the Agency for Healthcare Research and Quality (AHRQ) is TeamSTEPPS®, an evidence-based system that supports improving teamwork and communication skills with the goal of optimizing patient outcomes and improving patient quality and care”(Barry, 2015). Technology assist with improving patient safety by simplifying and streamlining by including electronic health record systems. Patient safety risk can be managed by enabling healthcare organizations to identify those who are a fall risk, by utilizing the assessment screening tools, and strategies, and goals associated with patient safety.
In this article we discussed the root cause analysis of an unassisted physiological fall and an unassisted fall. There were several factors analyzed to determine the root cause for the falls. Step by step each factor was assessed and evaluated as to its weight in contribution of the fall. It was determined what would have been the best evidence-based practice to use in preventing that fall. After evaluating the complete scenario, a fall prevention plan was created. An improvement plan was implemented to reduce the risk of an unassisted falls and assisted falls in healthcare settings, identifying the organizational resources to assist in improving a safety improvement fall risk plan.
Barry M., E. (2015). Better, Safer Patient Care through Evidence-Based Practice and Teamwork. Nebraska Nurse, 48(2), 19.
Chien, T., Goddard, M., Casey, J., Devitt, R., &Filinski, J. (2016). Evaluating individualized Falls Prevention for Clients with Medically Complex Conditions. Physical & Occupational Therapy in Geriatrics, 34 (2/3), 124-140. https://doi- org.library.capella.edu/10.3109/02703181.2015.1136367.
Dykes, P. C., Adelman, J., Adkison, L, Bogaisky, M., Carroll, D.L., Carter, E, Duckworth, M., Herlihy, L., Hurley, A.C., Khasnabish, S., Kurian, S., Lindros, M.E., Marsh, K. F., McNinney, T., Ryan, V., Scanian, M., Spivack, L., Shelley, A., & Yu, S.P. (2018). Preventing falls in hospitalized patients: Engage patients and families in a three-step prevention process to reduce the risk of falls. American Nurse Today, 13(9), 8-13.
Huey-Ming Tzeng. (2015). Patient Engagement in Hospital Fall Prevention. Nursing Economics $, 33 (6), 326-334.
Spruce, L. (2015). Back to Basics: Implementing Evidence-Based Practice. AORN Journal, 101(1), 106-112. https://doi-org.library.capella.edu/10.1016/j.aorn.2014.08.009.
Walker, L.J., O’Connell, M. E., &Giesler, A.L. (2015). Keeping a grasp on patient Safety. American Nurse Today, 10(1), 49-50.
In quality and safety care it is imperative that nurse implement evidence-based practices that support effective care, improving patient outcomes, and decreasing patient care cost.
It is important to collaborate with all disciplines involved in the project. The EBP team should agree on the scope, aim, and objectives before beginning the project. Prior to starting a project, the team should agree on the scope, aim and objective. Next is to identify the evidence and perform a critical appraisal using appraisal tools. The evidence must be from peer reviewed publications and credible sources. When implementing strategies, you should create teaching materials and provide teaching lessons.
Upon conducting a pilot test ensure you provide support to the team members and encourage feedback forms from each member. Make necessary changes as need based on the feedback from the team members. Perform as many pilot- test as needed. Implement the evidence-based plan in one designated area before applying it to other areas. Make sure you use evidence- based that you have previously reviewed.
Evidence-based practice benefits everyone in health care. Facilities that implement EBP are standardizing care for patients based on what has been shown to yield the best outcome. Evidence-based practice provides the value in value-based health care. Patient outcomes and core measures improve when care providers follow EBP. Evidence-based practice is more cost-effective, which is important for facility and provider reimbursement. Patients benefit knowing they are receiving care based on what works best rather than historical precedence. As a result, patients will be more informed health care consumers because they will understand what works and what does not, and then be able to base their treatment decisions on knowledge rather than on what their provider tells them to do. Health care providers are accountable for the care they give, and reimbursement is tied to their performance. Practicing evidence-based medicine and
As health care transitions from volume-based care to value-based care, it is imperative that perioperative nurses implement evidence-based practices that support effective care. Implementing evidence-based practice is a challenge but improves patient outcomes, standardizes care, and decreases patient care costs. Understanding how care interventions work and how to implement them is important to compete in today’s health care market. This ‘Back to Basics’ article discusses how to identify, review, and appraise research; make recommendations to implement new practices; evaluate the outcomes of the implementations; and make necessary changes to facilitate evidence-based practice.