Patient Safety Risk Inpatient Falls

Patient Safety Risk Inpatient Falls

PatientSafety Risk: Inpatient Falls

PatientSafety Risk: Inpatient Falls

and Rationale

Inpatientsfalls have become a common phenomenon in many healthcareorganizations. According to Miake-Lye,Hempel, Ganz, &amp Shekelle (2013),inpatient falls range from 2 to 8 falls per 1000 patients in a singleday. Many of these falls (about 30%) result in injury. Almost 4 to 6%of patient falls cause serious injuries such as fractures, brokenlegs, brain damage, excessive bleeding and sometimes death (Oliver,Daly, Martin, &amp McMurdo, 2004 Quigley&amp White, 2013). Falls worsen the health condition of patients andlengthen their stay at the hospital. As a result, falls are among theleading factors that contribute to higher health costs. According toMiake-Lye et al. (2013), in the United States falls has beenidentified as one of the medical errors contributing to high healthcosts. Various studies such as those conducted by Rowe (2013) andMeyer,Denham, &amp Battles (2010) indicatethat most of the patient falls that occur in hospital settings areavoidable. Unfortunately, very few studies have been carried toestablish the factors that contribute to inpatient falls to enhanceprevention interventions. Therefore, the topic on patient fall as apatient risk is highly relevant since its discussion will reveal someof the factors contributing to this health risk. The discussion willalso explain some intervention measures that can effectively addressthe health problem.

Humanand system errors contributing to inpatient falls

Severalstudies have documented the risk factors for fall among hospitalin-patients.AccordingtoOliveret al. (2004), factors such as improper balance, altered walkingstyle, history of falling, damaged cognition, depression, to name buta few contribute to inpatient falls. Oliver et al. (2004) argue thatsome other factors such as gender and race can determine theprobability of a patient falling. These factors include sex (femalepatients are more likely to fall compared to men) and race (a whitepatient has a higher risk of falling compared to other races).Carayon &amp Wood (2010) point out that there are system errors thatmight contribute to patient falls in hospital settings. Manyhospitals lack programs to prevent inpatient falls and enhancepatient safety. Some hospitals have devices such as bedside pressuresensors in acute care settings. However, such systems may fail due tolack of consistent maintenance and technical errors leading toinpatient fall in these contexts.

Accordingto Carayon&amp Wood (2010), several human error factors contribute toinpatient falls in hospital settings. For instance, in one hospitalbased in Scotland, an anesthetized patient fell off from theoperating table while under operation. The table had been tilted withthe patient`s head facing downwards to facilitate the process. Luckily, the patient did not get any injuries. However, upon the riskassessment of the incidence, various human errors were detected. Itwas later discovered that out of the ten healthcare workers attendingthe patient, very few were familiar with the regulations and safetyprecaution to prevent patient fall while under operation. Use ofmobile phones and chatting were other human factors that contributedto the fall.

Insightsfrom high-reliability organizations

Followinga rise in inpatient falls about 10 falls in a 1000 patients per day,Mercy Health-Anderson Hospital Cincinnati focused on addressing thechallenging issue adequately (Rodak,2013). The first step in preventing inpatient falls is themeasurement of compliance with best practices that prevent fall. Thehospital`s medical/surgical employees after measuring complianceidentified areas that need improvement. The hospital adopted astrategy that made it easier to determine their in-patients who had ahigh risk of falling. All the patients at high danger of falling worered socks. Therefore, throughout the hospital caution and extra carewas practiced around the patients in red socks. This strategy can beadopted across all healthcare organizations to identify a patienteasily at high risk of falling.

Followingthe incidence at the Scotlandhospital where an anesthetized patient fell from the operating table,various strategies to prevent such human errors were implemented. Oneof the strategies was education and creation of awareness amonghealthcare employees on all the rule and regulations to preventpatient falls. According toRowe (2013), many healthcare organizations overlook the importance oftraining band educating their employees on why and how to preventpatient falls. Identification of the patient with high risks offalling is not a valid strategy when used solely. According toQuigley and White, high-reliability healthcare organizations combinea variety of strategies to address patient falls efficiently.

Strategiesfor assessing and reducing risks related to patient falls

Accordingto Oliver et al. (2004), one of the tools that have proved to beuseful in measuring risks associated with patient falls is known asFalls Risk Assessment Tool (FRAT). FRAT was invented back in 1999comprises three sections. The first section helps a patient to knowthe fall status risk. This part acts as a screen through whichpatients and healthcare givers can categorize the patients in termsof fall hazards. The second part is a checklist that explains thevarious factors that can contribute to patient falls. The lastsection is the action plan, describing the strategies andinterventions that can be used to prevent patient falls.

Accordingto Sahota et al. (2014), apart from bed and bedside chair pressuresensors, there are a number of other approaches that can beimplemented to reduce the risks of patients’ falls in hospitalsettings. People who are recognized by FRAT to have a high likelihoodof falling, healthcare organizations can provide safety companions tomonitor their movements. Patient need movements away from their bedsto maintain their strength and avoid complications of bed rest.Therefore, it is important for hospitals to ensure the patients withhigh risks of fall are continuously given support to prevent falls.Nurses, physicians, and other healthcare givers should be regularlytrained in the skills and knowledge on patient fall prevention (Rowe,2013 Meyer,Denham &amp Battles, 2010).The hospital staff should also be sensitized to the need to complywith the set rule of conduct in relations to patient fall prevention.

Involvingpatients and patients’ families in addressing the issue of patientfalls

Patientsafety risks surrounding patient fall can be addressed effectively ifthe patients and their family members are involved in theintervention initiatives (Miake-Lyeet al., 2013). The Patient Fall Prevention training should includepatients and their families, to enhance their knowledge and skills onhow to prevent falls. It is important for Patient Fall Preventionstrategies to consider patient`s point of view on how best thepatient safety issue can be addressed. Organizations can complementintervention strategies with fun activities such as online games,which involve the patients and their families, with an aim ofenhancing their awareness and knowledge on how to avoid unnecessaryfalls(Quigley&amp White, 2013). Preventionof patient falls is not only needed in hospital settings but also inout-of-hospital settings. Therefore, it is important to includepatients and families in prevention fall training to equip them withthe skills needed to prevent falls when they get discharged fromhospitals.


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Sahota,O., Drummond, A., Kendrick, D., Grainge, M. J., Vass, C., Sach, T.,… &amp Avis, M. (2014). REFINE (REducing Falls in In-patieNtElderly) using bed and bedside chair pressure sensors linked toradio-pagers in acute hospital care: a randomised controlledtrial.&nbspAgeand ageing,&nbsp43(2),247-253.

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