Currently, patient falls remain a common adverse event occurring as a result of a multitude of complications that occur within the hospital and healthcare setting. While not all falls result in harm, some do and some even result in death (Parachute, 2015). This is a major concern as all patients seek medical services in hospitals in order to receive safe care and reach a state of wellness. In an effort to reduce the number of patient falls and adverse events that occur as a result of falls, the question arises: What best available evidence-based practice is available to help decrease the rate of falls in adult patients that are staying in the hospital? This quality improvement project will focus on identifying problems that lead to and ultimately cause falls, analyze these causes, and address them with the best, available evidence-based practice and interventions to reduce fall rates in Woodhall Park Care Community.
The Registered Nurses Association of Ontario (RNAO) estimates 700,000-1,000,000 patients in hospitals fall yearly. This is an alarming rate, as about 30-50% of falls result in an injury (RNAO, 2015). Falls can result in no injuries, minor injuries, major injuries, and even lead to death. Most common injuries can include soft tissue injuries, fractures, head injuries, decreased mobility, independence, anxiety, and death (Public Health Agency of Canada [PHAC], 2014). Up to 36% of cases that result in serious, major injuries can contribute to death within one year (Lizarondo, 2016). In addition, falls in hospitals lead to a longer length of stays resulting in an average of 12.3 days longer and an increase in healthcare costs averaging to a 61% increase (Avanecean et al., 2017). These rates show why Centers of Medicare & Medicaid Services (CMS) continue to name patient falls and resulting injuries as a sentinel event.
To start analyzing the causes behind acute care setting falls and searching for the most current evidence-based practice, a definition of falls must be identified and a research question must be established first. The World Health Organization (WHO) defines a fall as "an event that results in a person coming to rest inadvertently on the ground, floor, or other lower level" (n.d.). To aid in the literature searches for the best, available evidence-based practice a research question was established by using the PICO template and format. The identified population in the case study included the adult patient admitted to the hospital, specifically a medical-surgical department unit. After the initial literature search, it was found that not one single intervention on its own would prevent falls, therefore, it was decided that it would be of better benefit if a fall prevention bundle was composed of best evidence-based practices as the intervention. As a comparison, already established standard care and the available data could help identify if the new intervention improves fall rates by reducing them, making this our outcome. This results in my research question: Will the use of a multi-factorial approach by using a fall prevention bundle composed of best available evidence-based practice help to decrease the number of falls in adult patients that are staying in Woodhall Park Care Community?
Falls Quality Improvement Initiative
At Woodhall Park Care Community, the facility is continuously looking toward reducing the number of falls that occur, as well as working proactively to mitigate the potential risks for falls upon admission to the facility. Some ways that the facility has started to reduce these risks are through fall risk assessment, which is completed upon admission as well as quarterly. The facility also works to provide fall interventions to high-risk patients before an incident occurs. We are currently working on going to an "alarm-free" facility, as studies have proven the negative effects alarms have on patient safety and quality of life. Another aspect we are working towards is medication reduction as poly-pharmacy can be a major contributing factor resulting in falls.
Quality Improvement Principles
The multicomponent approach for preventing the patient fall is adopted. Each hospital uses a variety of methods (e.g., movement alarms, alert wristband, and patient education) for fall prevention. The methods may vary slightly from hospital to hospital. But, I think that by combining these methods properly, we can come up with the best systems to safeguard the patient from falls. For example, in our hospital, we have some fall prevention methods, such as fall prevention video watching, bed alarms, non-slippery socks, and yellow door signs. However, I think how to put them together into the fall prevention strategy is also very important.
The role of leadership is crucial to achieving the best outcome by fusing multiple components. In our hospital, we check once a month if a fall accident has occurred. If there was no any accident, we encourage by congratulating each other. However, if fall accidents have occurred, we try to prevent further accidents by identifying what the problem was and what components were missing. Each patient's assessment is used to protect the patient from falls by applying appropriate components to each patient. Such a strategy is not determined by a nurse alone but is decided through dialogue with other health care practitioners as well.
Involvement and Roles in the Quality Improvement Initiative
While working toward reducing falls through fall prevention programs within the facility, Registered Practical Nurse (RPN) or Registered Nurse (RN) must also come up with a realistic goal that we are trying to reach. Through our alarm reduction program, one goal would be to reduce the number of alarms utilized by 50% within 6 months of initiating the alarm-reduction program. Another goal for overall fall reduction is that the overall amount of falls that occur within our facility will decrease by 30% within 90 days. The outcomes are measured by our Quality Assurance Nurse who assesses all facility accidents and incidents as well as the interventions and their surrounding circumstances. The QAN is able to identify within our monthly Quality Assurance and Performance Improvement (QAPI) meetings what day of the week that most falls occur on, as well as the time frame that most falls occur within. Through QAPI, we formulate Performance Improvement Plans (PIP's), through established concerns for patient or staff safety whether it may be falling, worsening skin or pressure issues, lack of staffing, etc.
In our ability to create change and reduce falls for patients, as we roll out new processes to do so - we must effectively communicate all aspects of our plan. In order to create change, we must ensure that our staff is well equipped with the materials that will help them understand why we are making changes. With that I would like to see a mandatory staff meeting, to review falls, the prevalence as well as the overall damage it can have on patients and their quality of life. Understanding why change occurs gets staff involved and makes them think about the choices they make while providing care, as well as adding a heightened awareness to fall prevention. Even after educational meetings, we can utilize "oversight by a safety committee." (Jackson, 2004). It is obvious that "successful fall-reduction programs must begin with staff and management commitment." (Jackson, 2004). Members of the "fall committee" or safety committee, must be able to effectively listen to staff about further concerns - "employees should feel that leaders care about what they say." (). Feeling like they are not only heard but respected and that their ideas are taken into consideration in regards to a plan of care is accepted and often aides with creating change within a facility.
The staff that are educated need to continue to educate others on information learned, and continuously work as a team to be mindful that alarms are not being utilized anymore, as well as being mindful when adding new medications to a patient plan of care that may cause further risk for fall. Staff need to be continuously educated on the initial and ongoing assessment of patients to identify risk and reduce incidence through appropriate intervention including monitoring. The Fall Risk group at the facility needs to be consistent and persistent about making changes and can be used as the "safety committee" when providing oversight of these continued changes as staff adapt.
Analysis of Initiative
People, environment, materials, methods and equipment are five possible categorical causes for inpatient falls. These categorical causes were placed together in a fishbone (also known as a cause-and-effect) diagram to show the cause-effect relationship of inpatient falls (see figure 1. When a patient falls, people have a tendency to blame others for the complication. Sometimes an error contributing to a fall may involve staff competence, staffing complications, the inappropriate hand-off between staff, and lack of support from other hospital staff, inadequate risk management, and lack of assessment of fall prevention strategies. A patient's physiologic condition such as low vision, impaired cognitive function, and/or impaired mobility can also lead to patient falls. The physical environment where a fall occurs could also be a contributing factor. The size, organization, and storage of the room itself could cause a patient to fall. Poor lighting, far distanced toilets, an unsafe working condition such as spills, and poor room designs are also contributing factors for patient falls. Materials can also be another causative factor for patient fall. Flooring materials such as surface patterns or colours could create an illusion of steps that might result in a fall. Unsafe materials such as socks or shoes without anti-slip or the proper grip can facilitate falls.
Occasionally, a fall can be attributed to an error in the methods used to assess and grade fall risk. These method errors could include lack of communication about fall risks, ineffective assessment of fall risks, and lack of safety practice to prevent falls. Fall assessment and communication seem to be the most important predictors when it comes to methods to prevent a fall in the hospital setting. Inappropriate or insufficient use of monitoring methods, such as hourly rounding or alarms, can increase the risks of patient falls. Equipment could also be blamed when it comes to falls. Lack of safe and appropriate handling, insufficient quantity of fall prevention equipment (non-skid socks, signs, bed alarms, chair alarms, etc.), and malfunctioning equipment such as call lights. Lack of bed or chair alarms, inadequate size of beds, mattresses, walking aids or wheelchairs, and handrails distance from the bed, chair, or toilet could place patients at a higher risk for falls.
Target Conditions and Goals
The primary target, with fall prevention interventions in place, is it to decrease the rate of falls in hospitals when implemented in its medical-surgical units. Baseline metrics to determine current fall causes will be used to help reach the goal of a decreased number of falls within the hospital setting. Daily assessment, documentation, and feedback will be used to help determine the improvement of fall rates.
A fall prevention committee will be comprised of unit nurses to report to nursing and risk management to collect and verify compliance with fall prevention key indicators. The goal is to ensure compliance, foster an environment of safe nursing practice with fall prevention, and serve as individ...
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