Paper Example on Quality Improvement: Patient Falls in Woodhall Park Care Community

Introduction

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. 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.

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Background of Problem

The Agency of Healthcare Research Quality (AHRQ) 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 (Avanecean, Calliste, Contreras, Yeogyeong, & Fitzpatrick, 2017). 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 (Avanecean et al., 2017). 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 our 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?

Prevention Knowledge Principles

Some ways that Woodhall Park Care Community have started to reduce these risks are through fall risk assessment, which is completed upon admission as well as quarterly. We also work 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 Outcomes

While working toward reducing falls through fall prevention programs within the facility, we 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 can be measured by our Quality Assurance Nurse who assesses all facility accidents and incidents as well as the interventions and their surrounding circumstances. She 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.

Communication

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." (Roussel, p. 231). 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.

Data Flow

Survey-required data is available within our facility on each unit next to either exit doors, or next to our elevator. All survey results are maintained at wheelchair level so that all patients, as well as their families and staff members, have access at reviewing facility data. However, data retrieved from PIP's that are completed in the facility were not always available for everyone to see. Our quality assurance nurse has just recently made a board in our main entryway to allow staff, patients, and their families to be more aware of the performance improvement plans that our facility is working toward. "The use of data analytics can support nurse leaders through change processes." (Roussel, p. 291). Data Analytics are supportive documents like graphs and numerical data that can identify the progress of our performance improvement plans. This should be made accessible for all members of the facility to review. Seeing progress can aide in staff working even harder to meet our desired goals of reducing falls and alarms. Nurse managers can also utilize spreadsheets to produce documents and manipulate data into information that staff can make sense of. These spreadsheets can be specified in relation to the number of alarms the facility utilized when we initially started the alarm reduction program and the amount at each quarterly meeting. They can also review falls, breaking them down to specifics like a day of the week and time frames. Being aware of the high risk of falls occurring on a Monday between 2 and 3 in the afternoon will bring heightened awareness to staff members and patient safety during those specific times.

Needed Leadership

"Fall prevention improves the quality of life of older people and their families and ensures the continuity of independently executed functions." (Uymaz, 2016). Nursing leaders need to empower their staff with this message, this will help to solidify excellence in the delivery of nursing care to patients. The nurse leader needs to share the goals of the fall-reduction programs that the facility is working toward. By sharing this goal, we create a vision for the staff to create. "A vision statement sets the tone and charter for where the organization sees itself in the future." (Roussel, p.231). The nurse leader should also set expectations for her staff - in this instance, it may be for the reduction of alarms. Working together to reduce the amount the floor has. The nurse leader can also portray her expectation that before starting a new medication for a patient, the nurse identifies whether there will be a drug to drug interaction and communicate these concerns to the prescribing physician. Though they may still want the patient to have this medication, we can still review the overall risk versus benefit for the patient. "After the leader shares the expectations, the staff will know what is needed for compliance and can be successful in their roles." (Roussel, p. 232). Though there will continue to be challenged in regards to patient falls, failure of fall-reduction programs, nurse leaders and nursing staff need to work together to maintain patient safety and work toward the same vision in mind.

Cause Analysis

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 3). 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 risk...