Literature review

QILiteratureReviewIssue.docx

Literature Review: Problem/Issue

According to Porter et al. (2018) the focus is on the elements that need to be reviewed that contribute to preventing falls. It identifies the miscommunication and the lack of knowledge between the clinical team when it comes to patient falls. This study involves clinicians with both nursing and non-nursing backgrounds at a large academic medical center between October 2013 and March 2014. This article identifies many underlying factors that play a role in fall prevention, instead of focusing on specific patient needs, it is focusing on the healthcare team’s involvement.

In the results section of the study it discussed the team’s methods of determining a patient’s fall risk. For example, in the study the nurses use FRAS (fall risk assessment scale) to determine fall risk however the non-nursing staff has no knowledge of FRAS and use other methods to determine fall risk such as using BEERS to determine a patient’s fall risk. Miscommunication between nurses and non-nurse staff is an issue as well, the nurse staff may place the FRAS score in the patient’s chart or place a leaf outside the door to signify fall risk however the non-nurse staff has no idea what these things mean.

Fall prevention interventions based on the specific unit and the overall unit layout play a role, some units are designed in a way that might make it difficult for a nurse to be close to all their assigned patients. And last is the responsibility for fall prevention, majority of the participants identified nurses as having primary responsibility for fall prevention however “many participants indicated that while nurses ‘own’ the responsibility for leading fall prevention, it takes coordinated interprofessional teamwork for evidence-based fall prevention strategies to succeed” (Porter et al., 2018, p. 28). In conclusion nurses should take the lead on fall prevention however the interprofessional team should work as a whole and communicate for effective fall prevention.

According to Venema et al. (2019) an observational study was conducted on falls in rural hospitals in Nebraska focuses on unassisted falls. This study is based on rural hospitals and the data is compared to larger studies. The article provides statistics on falls such as one million hospitalized patients fall annually. The national benchmark for falls is 3.44 out of 1000 patient days. Venema et al. (2019) noted that one-fourth of falls cause injury, increasing medical cost to $7000 for each injury that has occurred and along with that hospitals are not reimbursed for the treatment of injuries related to inpatient falls.

The study defines falls as “a sudden, unintended, uncontrolled downward displacement of a patient’s body to the ground or other object” (Venema et al., 2019, p. 2). The study looked at demographic data such as age, unit type, and diagnostic category to assess fall risks concluding that majority of falls were older patient’s inpatient for acute care associated with respiratory, orthopedic, or cardiovascular diagnoses. Falls were also more likely to occur in the evening hours and with patients that are cognitively impaired. There is an increase in falls when there is lack of access to a call light for the patient or when there is no bathroom schedule for the patient. In the discussion it is noted by Venema et al. (2019) that the AHRQ does not recommend the use of bed alarms as a reliable fix to preventing falls, the research of others does not show bed alarms as being effective. It is better if the staff rely on scheduled toileting to ensure the patient gets to the bathroom with assistance, to prevent falls.

Group2-NavarreteOmogiadeRodriguez-IntroductionSection.pdf

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Introduction

Medication errors pose significant risks to patient safety and healthcare outcomes,

emphasizing the importance of addressing them. Patient education is recognized as a key strategy

in preventing such errors, as informed patients are more likely to adhere to medication regimens

accurately. According to Nguyen, Gibson, and Wembridge (2022), excerpts delve into the

importance of patient education in mitigating medication errors during transitions of care,

particularly at the point of discharge from healthcare facilities. The prevalence of errors in

discharge summaries (DSs), with up to 80% of DSs containing inaccuracies, especially in

patients with polypharmacy. Although pharmacy-based interventions have shown improvement

in DS accuracy, resource constraints often limit their widespread implementation. The

intervention involved reviewing DSs by an intern pharmacist and comparing them with discharge

prescriptions, resulting in significant reductions in medication errors.

Transitions of care (TOC) are critical junctures where patient outcomes can be

significantly impacted, particularly for patients at high risk of medication errors. Although

pharmacist-led post-discharge telephone counseling has shown positive effects on patient

outcomes, challenges remain regarding successful patient contact. Recent research concludes that

the pharmacist-led TOC service effectively increased contact points with high-risk patients,

resulting in a low readmission rate and positive patient satisfaction. Suggesting that integrating

pharmacy residents or students into such programs could help address financial and workload

barriers. (Crannage et al., 2020)

This issue is highly pertinent in the healthcare setting due to the significant impact that

medication errors can have on patient safety and overall healthcare outcomes. Medication errors

are unfortunately common and can result in adverse drug events, prolonged hospital stays,

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increased healthcare costs, and even patient mortality in severe cases. As frontline healthcare

providers, nurses play a crucial role in medication administration and patient education, making

them particularly invested in strategies aimed at reducing medication errors. Nurses are

advocates for patient safety, and understanding how patient education materials can contribute to

reducing medication errors aligns with their professional values and responsibilities. Researching

effective strategies for reducing medication errors through patient education aligns with the goal

of improving the quality of patient care.

As nurse students there is a personal interest in patient education and medication safety,

based on personal experiences and the desire to contribute to improving healthcare practices.

Utilizing patient education materials to address medication errors offers numerous advantages

within the healthcare setting. Overall, choosing this topic allows nurse students to explore an

issue that directly affects patient outcomes, contributes to their professional development, and

aligns with their commitment to providing safe and effective patient care.

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References

Crannage, A. J., Hennessey, E. K., Challen, L. M., Stevens, A. M., & Berry, T. M. (2020).

Implementation of a Discharge Education Program to Improve Transitions of Care for

Patients at High Risk of Medication Errors. The Annals of Pharmacotherapy, 54(6),

561–566. https://doi-org.resu.idm.oclc.org/10.1177/1060028019896377

Nguyen, A., Gibson, S., & Wembridge, P. (2022). Improving medicine information on discharge

summaries through implementation of a reconciliation‐based intervention. Journal of

Pharmacy Practice & Research, 52(6), 454–457.

https://doi-org.resu.idm.oclc.org/10.1002/jppr.1828

https://doi-org.resu.idm.oclc.org/10.1177/1060028019896377