Walden NURS 4220 Introduction, Analysis of Existing Evidence, and Quality Improvement Process

WK 1 With the reference:

An increase in falls in the hospital setting is a problem I've identified as a growing issue in my profession. My mentor, with whom I work, was the primary leader I consulted for my article. Most people associate falls with the elderly, but according to the conversation with my mentor shared with me, that is not the case. Just for the month of July, we had a huge amount of falls across the hospital, many of which could have been avoided. Because there are a large number of patients who have not only fallen but also been hurt, I chose to address this subject as my capstone paper problem. There were certain mechanisms that could have been put in place and a few places that could have been improved while discussing this with my mentor. Falls in the healthcare setting and the injuries they cause are the most commonly reported adverse events in the inpatient setting among adult patients (Quigley et al., 2016). I hope to find good information from my hospital to help prevent falls.

For measurable-would be to decrease fall rates by 10%?

NEEDS TIME FRAME!!!!

References

Quigley, P. A., Barnett, S. D., Bulat, T., & Friedman, Y. (2016). Reducing falls and fall-related injuries in medical-surgical units. Journal of Nursing Care Quality, 31(2), 139-145. https://doi.org/10.1097/ncq.0000000000000151

WK 2 With All the 5 references to use

I've spent the last nine years working in an emergency room, and I've seen a lot of falls that should have been avoided. After consulting with my charge nurse, this class's mentor, and a few other ER nurses, we believe that the majority of ER falls are avoidable. According to the charge nurse, the ER has had difficulty preventing falls since there appears to be a breakdown in communication between the interdisciplinary team and the nursing staff in identifying high-risk fallers. A fall risk assessment is not used by ER nurses to identify patients who are at high risk of falling. Although the EMR contains a fall risk tool, the ER nurses claim that they do not have time to use it.

All falls must be reported using our PRISIM report system, which is an electronic database-based incident report. Managers, nurses involved in the falls, and risk management attend weekly risk meetings to analyze how the falls could have been avoided. Regrettably, the meeting's findings are not shared with the nursing staff, which could help prevent future falls. Falls are a big concern to patient safety, and it was acknowledged during my interviews that increased communication and usage of the fall risk tool, as well as the devices we have to help avoid falls, are required. This is critical because falls impose a large financial impact on everyone who is affected.

If you can't measure it, you can't improve it, according to a basic premise of quality measurement (5. How do you measure fall rates and fall prevention practices?, 2013). As a result, as part of a quality improvement program, fall rates and fall prevention techniques must be counted and tracked. To assist decrease patient falls, the research advocates having a standardized fall procedure in place, as well as hourly rounding by all staff (Goldsack et al., 2015). Hourly rounding should also be patient-centered and adapted to the needs of the community. Communication among healthcare team members is also vital in decreasing falls, according to research, and fall prevention is the responsibility of all personnel (Goldsack et al., 2015). Our stretches have built-in fall alarms that the nurses are not using, which is another tool we have in the ER.

All fall prevention initiatives, including evaluation, interventions, and education, are evaluated by the hospital.  The five referance3s I will be using along side with my interviews are the following: “Preventing Falls in Hospitals”, “Hourly rounding and patient falls: what factors boost success?”, “Prevention of falls in hospital”, “Advanced Practice Nurse-Led Statewide Collaborative to Reduce Falls in Hospitals”, and “Preventing falls and fall-related injuries in health care facilities”.  I feel with all this I will have enough to plan how to reduce falls in the ER by 10%.

 

 

References

5. How do you measure fall rates and fall prevention practices? (n.d.). Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html

Advanced practice nurse-led statewide collaborative to... : Journal of nursing care quality. (n.d.). LWW. https://journals.lww.com/jncqjournal/Abstract/2017/04000/Advanced_Practice_Nurse_Led_Statewide.6.aspx

Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls. Nursing, 45(2), 25-30. https://doi.org/10.1097/01.nurse.0000459798.79840.95

Morris, R., & O'Riordan, S. (2017, August). Prevention of falls in hospital. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297656/

Preventing falls and fall-related injuries in health care facilities. (2015). A complimentary publication of The Joint Commission, (55). https://www.jcrinc.com/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_55_falls_4_26_16.pdf