replies

emaileeworksheet.docx

Structure or Process Indicators

List the steps or key pieces that your clinical practice guideline or systematic review suggest that should be in place to improve outcomes (these become your measurements):

	Indicator	What data will be collected
1.	High fall risk patients; dementia, post op, cognitive and visually impaired, hypotension, urinary incontinence, diarrhea	Audits, documentation in system
2.	Dark room, clutter on floors, wires/ tubing	Audit
3.	Low inventory of non-skid socks, lack of gait belts	Audit
4.	Lack of signs in room, white board not being updated	Audit
5.	Incorrect fall assessments	Documentation in system
6.	Lack of hourly rounding	Audit
7.	Delayed call light response time	Audit
8.	Patient belongings out of reach	Audit
9.	Lack of education to room orientation/ education on fall risk/prevention	Documentation in system
10.	Pain medications/ diuretics/ antihypertensives/ IV meds	Documentation in system

Plan for Improvement (for each item listed above, complete the following):

Indicator: All patients on med-surg unit that are high fall risks will have correct documentation charted.

This is key to improving outcomes because: incorrect documentation can lead to an increased risk of failures.

Operational definition: based on environmental and social support of nursing staff

Numerator: Patients that fall in high fall risk category

Denominator: All patients who are in high fall risk category

Data collection method

Who	Nurses
What	Fall assessment documentation
Where	Med surg patient chart
Why	The evidence shows incorrect fall risk assessment, which puts the patient at risk for falls
When	When the patient is admitted to the unit and daily after
How	By auditing nurses charting

Goal for this indicator: 100% compliance, all nurses to have a better understanding of proper fall risk assessment, charge nurses to audit charting, white boards updated properly.

Benchmark 100% compliance