Running head: PATIENT FALLS

Quality Improvement Process for Patient Falls

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Quality Improvement Process for Patient Falls

The majority of these authors attended clinical on 4 North Butterworth, where there has
been a constant struggle with patient safety. Because of this, the group decided to do a problem
that has been a constant struggle on that unit. The problem is the safety of patients. There has
been a disproportionate amount of falls on 4 North as opposed to other units. Because the unit is,
for the most part, orthopedics and trauma, there are a high number of problems with patient
mobility. This patient population has problems with mobility and only three nursing technicians
for the unit during a shift, so it can be difficult for a nurse technician to get to all of the patients
in a timely manner and this can cause patients to try to get up by themselves, which can lead to
patient safety concerns. The purpose of this paper is to look at the quality improvement topic of
safety, design a data collection method, establish a goal for change, identify strategies to help
achieve the proposed change, and design a process to evaluate movement toward the intended
goal.
Identifying Clinical Need
In terms of a hospital setting, falls are always looked at as a universal quality
improvement goal. While that is true, units with a higher acuity of patients, like 4 North, need to
be especially mindful of this quality improvement goal. On 4 North, the group discovered a need
for quality improvement after seeing how frequently falls occurred on the clinical unit. The
proposed change is to increase the use of fall risk interventions and by doing this, decreasing the
number of falls.
Many healthcare providers need to put more emphasis on interventions used in
preventing patient falls. Shever, Titler, Mackin, and Kueny (2011) bring up a good point in that
bed alarms, rounds, sitters, and moving a specific patient closer to the nurses station are some of

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the most common interventions used to prevent falls. In practice however, it has been seen that
some bed alarms never get turned back on after getting turned off to get a patient up. Sitters for a
patient that is a fall risk is almost unheard of on 4 North, and although nurses should be rounding
on their patients every hour, with normal four patient loads of varying acuity, sometimes that is
just not possible. These interventions need to be improved upon in a way that benefits both staff
and patients. To do this, perhaps do a training exercise on turning the bed alarms back on, or hire
on more staff to be able to better accommodate the higher acuity of 4 North so that patients
would be able to be checked on more often.
Designs an Interdisciplinary Team
In developing appropriate measures to decrease fall risks, it is imperative that the entire
interprofessional team communicates amongst themselves and with their patients regarding
appropriate promotional measures for patient safety. The physicians, pharmacists, physical and
occupational therapists, nurses and nurse managers, nurse assistants and technicians, as well as
family members must all be educated on and involved with interventions to promote safety. With
regards to physicians and pharmacists, it is imperative that they take thoughtful consideration
when prescribing, reviewing, or preparing medications that increase a patients fall risk (Lamis,
Kramer, Hale, Zackula, & Berg, 2012). Falls Risk Scores must be taken and precautions such as
Falls Risk patients must be identified. Once higher risk patients are identified, it is important that
nurses are aware of Falls Risk patients. During shift change, nurses should verbalize who is on
these precautions and give a brief hand-off assessment on the patients current status.
Information such as dizziness, lightheadedness, poor gait, or confusion are all important pieces
of information to assess for and be aware of. Nurses and technicians should also work diligently

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to answer call lights as quickly as possible so that a patient does not attempt ambulation on their
own
If a patient is identified as a fall risk, then further interventions may follow. Appropriate
interventions include educating the patients family on cautionary measures while in the hospital
and symptoms to be aware of that could indicate higher risks. Prior to a patient discharge, it is
important that patients learn to properly ambulate on their own and develop a steady gait, and so
involving a physical therapist should be an intervention for the patient. Another intervention once
the patient leaves the hospital is to have an occupational therapist consult with the family on
hazards in the home that could potentiate a fall.
Nurse technicians, as well as nurses, must be aware of the patient bed alarms and
remember to always put the bed in the lowest and locked positions prior to leaving a patient
room, while also ensuring the call light is within reach. Prior to patient ambulation, adequate
lighting should be provided, with ambulatory devices provided if requested by the patient, and
that gait belts, grip socks or shoes are donned.
Nurse Managers are then responsible for ensuring that incoming staff are adequately
educated on fall prevention and that the current staff remains up to date. Nurse Managers should
then implement fall risk programs, ensure that falls are all accounted for, and that if staff needs to
collaborate as an interprofessional team, that they do so.
Data Collection Method
According to the Agency for Healthcare Research and Quality (n.d.), a concept that can
be agreed upon across the board, is that for quality improvement efforts, if something cannot be
measured, it cannot be approved. Fall Risk is an important component of quality and safety, but
before determining data collection methods for fall risks, it is important that an institution has a

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universal definition of what is considered a fall. Once a definition for a fall is determined, it is
imperative that staff feel comfortable reporting falls and not pressured to under-report cases that
may otherwise seem minor in an effort to compare favorably with other units. Falls must then be
accurately documented and reported along with the number of occupied beds on that given day,
and according to the agency aforementioned, if there is a repeat faller, it is important to make
note of that patient in the event that they skew the data.
Defined by the National Database of Nursing Quality indicators, a fall is any incident in
which a patient is on a surface that a staff member would otherwise not wish to find them, and
occurred with or without injury. Falls due to physiological and non-physiological reasons, as
well as those that are assisted or unassisted, must be recorded. This fall rate could then be
compared to the injurious fall rate, which measures a patients level of injury related to a fall
(Agency for Health Care Research and Quality, n.d.)..
Suggested methods of calculating fall rates are person 1,000 occupied bed days, so that
the number is not a reflection of low-fall months when patient census was low or high-fall
months when the count was high. To accurately represent the fall rate, the number of falls are
divided by the number of occupied bed days within that month, and multiplied by 1,000. An
example sited on the agency website was an instance in which three falls occurred out of 857/900
occupied beds. When 3 is divided by 857, and then multiplied by 1,000, the rate is 3.4 falls out of
1,000 patients (Agency for Health Care Research and Quality, n.d.).
Establishing Outcomes
Establishing outcomes as part of the care plan should be measurable and include a plan
on how to meet goals. The nature of falls is a responsibility that falls into a nursing-sensitive
outcome. Measurable nursing outcomes for falls are going to reflect the responsibility the nurse

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has to the patient to perform proper assessment and interventions in regard to fall risk prevention.
Nurses at the forefront of care, should be able to identify which patients are considered high
risk for falls, (Callis, 2016). They also have a responsibility to be able to identify modifiable
and non-modifiable risks. The nurse management team needs to implement unit or facility goals
and ensure staff education for fall prevention.
To do this communication with staff about meeting prevention standards is a must.
Education of staff, patients, and family is key. Break rooms are a great place to have a bulletin
board for quality improvement areas, such as fall. A board stating how many falls last month, the
date since the last fall and how the unit compares is a great visual. Lists of medication classes
that put the patient at an increased risk for orthostatic hypotension could hang above the Pyxis,
as reminders to educate patients and family about rising slowly before ambulation. Fall risk
goals should be zero falls within six months time, with a reality of less than previous average
with new precautions. The budget for the unit should cover print materials.
Implementing Strategies
Implementing change to fall risk procedure is a process that builds from a supportive
process with respect to patient care needs while providing evidence-based practice from the care
team. These strategies support the planned outcomes by taking steps for change in practice that
can improve quality. Education remains a strong foundation to fall risk prevention. Per YoderWise (2011) quality improvement can use outcome goals and past errors as a way to plan for
future implementation and to measure progress. Quality improvement for fall risks start with the
reports of national standards of care, facility and unit reporting. This baseline of fall history
incidence reporting can help guide towards an approach to prevention. The staff takes the
information and implements it during interactions with the patient, assessment, and their

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documentation. Steps to ensure implementation can include a list that asks if the nurse/staff
remembered to: check vitals, assess medication risks, set clear ambulation goals, assess the
environment, do hourly rounds, and double check alarms with each contact.
Evaluation
With the implementation of a new process, it is imperative that the process is routinely
evaluated for effectiveness. In the implementation of a new fall risk policy, compliance of the
staff is one measure that is essential in its working to eliminate falls. One way to ensure that the
staff remains compliant with the new process is to implement random patient audits, where the
charge nurse or manager will go throughout the unit and assess a patients room for the bed alarm
being set, and that the appropriate measures are in place. The patients chart can also be
evaluated to ensure that hourly rounds have, in fact, been completed.
The National Institute for Health and Clinical Excellence (2002) defines a clinical audit
as A quality improvement process that seeks to improve patient care and outcomes through
systematic review against explicit criteria and the implementation of change (n.p.). Evidence
shows that with appropriate and simple use, it can be an effective tool for quality improvement.
In the event that an audit has been completed, and it has identified poor results, changes shall
need to be implemented to improve these results. In order to ensure the updated policies are
upheld, further staff training or making further changes to the policies may be required (Ashmore
& Ruthven, 2008).
A nursing theory that could fit the fall risk policies in the hospital would be Florence
Nightingales Environment Theory. This theory states that the nurse is to change the environment
in which the patient is residing in order to have a positive effect on their health (Maville &
Huerta, 2013). In the implementation of utilizing bed alarms, hourly rounds, and environment

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assessments, among the other changes that were listed, the nurse is ensuring to change the
patients environment to meet their needs and minimize the risks that the patient is exposed to,
and if implemented properly, this will result in a significant reduction of the number of patient
falls on the unit.
Conclusion
In conclusion, patient safety is an issue that needs to be addressed in the acute care
setting. Patient falls are an issue that is prevalent in many areas of the hospital, and there should
be interventions put in place to ensure that these adverse events do not occur. The patient care
teams will need to collaborate to ensure that the patients are frequently seen, and that
interventions patients who are deemed as a fall risk are enacted at all times. In ensuring these are
in place, and limiting the number of falls that patients suffer, this can improve the health care
environment as a whole, improve patient satisfaction with care, and decrease their length of stay.
In implementing these fall prevention strategies, the members of the group will work to develop
their attention to detail, and ensure that they keep patient safety as a top priority throughout their
nursing careers. The issue of patient safety is prevalent in the medical field today, and with
exemplary teamwork and leadership, this issue could become a problem of the past.

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References

Agency for Healthcare Research and Quality (n.d.). Retrieved April 18, 2016, from
http://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html
Ashmore, S. & Ruthven, T. (2008).Clinical audit: A guide: Allnurses are expected to take part in
clinical audits. Stephen Ashmore and Tracy Ruthven explain how it should be done.
Nursing Management (Harrow), 15(1), p. 18.
Callis, N. (2016). Falls prevention: Identification of predictive fall risk factors. Applied Nursing
Research : ANR, 29, 53-8.
Lamis, R. L., Kramer, J. S., Hale, L. E., Zackula, R. M., & Berg, G. (2012). Fall risk associated
with inpatient medications. American Journal of Health-System Pharmacy, 69(21),
1888-1894.
Maville, J. A. & Huerta, C. G. (2013). Health Promotion in Nursing (3rd ed.) Clifton Park, NY:
Delmar, Cengage Learning.
National Institute for Clinical Excellence (2002). Principles for best practice in clinical audit.
Oxford, Engl: Radcliffe Medical Press.
Shever, L. L., Titler, M. G., Mackin, M. L., & Kueny, A. (2011). Fall Prevention Practices in
Adult Medical-Surgical Nursing Units Described by Nurse Managers. Western Journal of
Nursing Research, 33(3), 385-397. doi:10.1177/0193945910379217
Yoder-Wise, P. S. (2011). Leading and managing in nursing (5th ed.). St. Louis, MO: Elsevier
Mosby.