Falls and Risk Management
April 25, 2016
Dr. Rachel Gonzales
Falls and Risk Management
In the hospital setting falls are prevalent for various reasons. According to Sullivan (2013), “Risk management is a component of quality management, but its purpose is to identify, analyze, and evaluate risks and then develop a plan for reducing the frequency and severity of accidents and injuries” (p. 77). This paper will address falls as a risk management issue; discuss methods to identify patients as a fall risk, methods to implement to reduce falls, and how to inform all staff of seriousness of fall issue. Furthermore, a comparison of three other facilities and ...view middle of the document...
The pilot program was for six months and in the time frame per the fall coordinator, the number of falls improved 83%. The methods introduced were yellow slippers to every patient with a fall score of 45 or higher and a wristband that identifies them as fall risk. Each room has a safe sticker on the bed sign identifier and on the door. This ensures the is staff aware the patient has a potential to fall. Another strategy is rounding on every patient once an hour. The charge nurse assigns a different staff member every to check the patients. During this rounding the four P's are addressed, does the patient have to potty, are they in pain, do they need positioning, or need personal belongings, not within reach. The staff will address immediate needs and inform the nurse and tech for needs that be lengthy. Other steps include a mobility aide assigned to the floor to assist with ambulating patients and providing range of motion exercises to that patient with orders. The mobility is required to report results to the nurse and document results including vitals. Other measures include bed alarms and chair alarms. If possible, the high fall risk patients are placed as close to the nursing station as space permits. The patients with cogitative impairment and a frequent fall history are rounded on every 15 minutes by a staff member. Last but not least our fall coordinator visits the floor daily to address the staff issues, concerns and speak with the patients. Risk Management Procedures Following Falls
Following a fall, these steps are followed. First, an assessment is completed prior to moving the patient if injury is suspected the patient is not moved until seen by the doctor. The physician, nurse manager or nurse on duty, and the pharmacist are notified. After stabilizing the patient, a fall huddle is done including the staff mentioned above as well as the other nurses and techs. This huddle informs everyone on the floor of the occurrence. There is a discussion as how and why the fall occurred if anything what could we have done to prevent it, and what we can do differently in the future. A post fall note is completed by the nurse addressing the incident and placed in the chart. This is another way to inform other staff that may not have been present. This process seems but it isn't. Risk management tracks the falls and provides a bar graph the shows our results. It is placed in the break so the staff can see the progress. The nurse manager is directly involved in weekly meeting and often requests a staff nurse to sit in. She believes this gives the nurses a better understanding of the importance risk management and why certain policies and procedures are in place. The risk management process and investigation are crucial to the success of hospital improvement and prevention. Patient safety is the most important...