Week8 Final Project

NORTHCENTRAL UNIVERSITY

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Student: Maria Duplantier

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DHA-7005	Dr. Ismaila Ramon
Healthcare Quality Management	Assignment 6– Discovering Root Causes of Falls in Organizations

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Discovering Root Causes of Falls in Organizations

Preventing patient falls is essential in long-term and acute care settings. Research indicates that falls contribute to about 40% of accidents in health care organizations which tend to result in injuries and deaths (Gazibara et al., 2014). As such, it is critical for hospitals to integrate proper strategies that can reduce or eliminate fall incidences. However, before deciding on which approach to incorporate, it is vital to identify the root causes of the problem. Fishbone Diagram is the commonly used tool to establish the causes of a particular issue in the organization. Therefore, this essay utilizes the Ishikawa diagram to elicit the primary causes of fall accidents in the healthcare facility to improve safety.

Part 1

Part 2

Equipment

The health facility does not have adequate bed alarms that patients can use to call for assistance from nurses. Because of this, patients in where there are no bed alarms record a high rate of falls and are also at a high risk of falling. Secondly, the bed alarms are not within reach for patients to send the signal promptly when at risk of falling. In many instances, patients tend to fall when trying to reach the alarms. Thirdly, the safety equipment such as electronic charting is also not available which increases the rate of fall accidents.

Process

Regarding process or procedures, the first cause of fall accidents is that the facility has failed to implement basic safety practices such as having low beds, ensuring adequate lighting is some wards, and incorporating side rails. Secondly, there is also improper use of restraints in specific wards. Thirdly, assessments on patient-specific needs are not adequately performed. It is usually through frequent evaluations that nurses can identify patients that are at a high risk of falling to put up an appropriate measure urgently (Dunne et al., 2014). However, in this facility, the review is done once a week which is not enough to establish the needs of patients. It is for this reason that the rate of fall accidents increased significantly.

People

Concerning people, the first cause of fall accidents includes a high number of patients. The rate of long-term care is increasing which surpasses the number of employees to receive appropriate care.

Materials

Regarding materials, the primary cause of fall accidents in the facility is the lack of vision and hearing assistance materials. Blind and deaf patients have no proper materials to assist them in navigating around the hospital which increases their risk of falling. Secondly, there are also no monitoring charts in nurses’ units that can help them to follow the progress of patients as well as identify those at risk of falling. Finally, there are no marks to differentiate those at a high risk of falling and those that are not to provide appropriate care.

Environment

The first cause that relates to the environment includes understaffing. Some nurses are working in double shifts which make it challenging to address all the patient needs due to tiredness and fatigue. In other words, nurses are overworked, and in some instances, they are not available or enough in the unit. As a result, the ratio of nurses to patients is high, therefore raising the risk of falling among patients. Secondly, the inexperienced staff is also a significant problem because the facility relies so much on interns who usually have less experience in acute and long-term care. Only a few nurses have adequate nursing experience. Thirdly, there is also low morale in the hospital which have increased turnover. Low motivation levels prevent nurses from addressing the issue of fall accidents effectively (Dunne et al., 2014). Additionally, the hospital has also small rooms that cannot meet the needs of a high number of patients. Sometimes more than two patients sleep on the same bed which increases falling risk. Finally, the floors are slippery, thus causing a high risk of fall accidents.

Management

About management, the first cause of fall accidents is poor overall culture to safety. The administration has not established an active safety culture, and most employees seem not to care a lot about fall accidents. They see it as a normal thing although patients are the ones footing the pain and injuries. They talk less about overall patient safety. Secondly, the commitment to safety is also relatively low. The management is not showing a lot of desire and morale to tackle the problem of fall accident among the patients (Williams et al., 2014). For instance, the administration rarely talks about patient safety concerning falls to employees as well as patients. Additionally, there is also inadequate training for nurses regarding patient safety. The facility has no appropriate training and development program to ensure consistent training of its staff.

Brainstorming Process

To gather information about the causes of falls in the facility, a staff meeting was called, and employees asked about the possible causes. The team also interviewed some patients to listen to their views about the problem. Finally, the team observed the various processes in the facility to identify the causes of fall accidents.

References

Dunne, T. J., Gaboury, I., & Ashe, M. C. (2014). Falls in hospital increase length of stay regardless of degree of harm. Journal of evaluation in clinical practice, 20(4), 396-400.

Gazibara, T., Pekmezovic, T., Tepavcevic, D. K., Tomic, A., Stankovic, I., Kostic, V. S., & Svetel, M. (2014). Circumstances of falls and fall-related injuries among patients with Parkinson's disease in an outpatient setting. Geriatric nursing, 35(5), 364-369.

Williams, T., Szekendi, M., & Thomas, S. (2014). An analysis of patient falls and fall prevention programs across academic medical centers. Journal of nursing care quality, 29(1), 19-29.