MEASUREMENT TOOLS

Micah Mackenzie Watson

The previous six year I  have been spent working with ages 18 and up. Since I've been working with a large variety of patients, I've realized that falls are a major issue among all ages. My unit experienced 26 falls in 2022, however none of them resulted in injuries. In the past, a few falls have left patients hurt and forced longer admission to the critical care floor; one patient was even transported to another hospital. Thankfully, there haven't been any injuries caused by recent falls.

The facility has been having trouble preventing falls, according to the director of nursing, who told me that once high-risk fallers are identified, there seems to be a breakdown in communication between the multidisciplinary team (IDT) and the front line nursing staff.

Patients who are at a high risk of falling are identified by the facility using a fall risk assessment, but he has discovered that the information is not always shared with the following shifts.

Every fall is reported to the nurse managers, and an electronic database verge incident report is filled up. For patients who have fallen more than once, daily risk meetings are held.

Unfortunately, the nursing staff is not often given access to the meeting's findings, which could assist prevent more falls. In addition, the nurses are required to record each shift while continuously monitoring the patients after any falls.

In order to find out if they think falls are an issue in the institution and what efforts they take to prevent them, I also spoke with four nurses working the day and nighttime shifts. Responses from the nurses' interviews were inconsistent. Some people were not aware that there were so many falls in 2022. 

Although they were unaware of the patients' most recent fall risk scores, they were able to identify a handful of the individuals they thought were at a higher risk. They added that due to the busy workday, they are frequently unable to round on their patients who are at a higher risk and significantly rely on the milieu therapists.

The safety of the patient is seriously threatened by falls. There has to be more contact between the IDT and the nurses who work directly with patients, it was agreed upon during my discussion with the director of nursing and the nurses. This is crucial because everyone affected by falls bears a heavy financial price. According to the literature, patient falls can be decreased by having a formalized fall protocol in place and hourly staff rounds (Goldsack, Bergey, Mascioli, & Cunningham, 2015).

The q15 minute safety checks must also be patient-focused and uniquely adapted to the needs of the population. Avanecean, Calliste, Contreras, Lim, and Fitzpatrick (2017) concluded that fall prevention is the duty of all employees and that communication among healthcare team members also plays a key role in preventing falls.