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Locate a safety improvement plan (your current organization, the Institution for Healthcare Improvement, or a publicly available safety improvement initiative) and create an online tool kit or resource repository that will help an audience understand the research behind the safety improvement plan and how to put the plan into action.Institution for Healthcare Improvement.

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Safety from Patient Falls: An Online Toolkit for Nurses to Understand the Research behind a Patient Falls Improvement Plan and How to Put the Plan into Action

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August 21, 2020

Institution for Healthcare Improvement.

Safety from Patient Falls: An Online Toolkit for Nurses to Understand the Research behind a Patient Falls Improvement Plan and How to Put the Plan into Action
I. Table of Contents
1. Introduction
1.1. The problem………………………………………………………………………… 3
1.2. Importance for nurses……………………………………………………………. 4
1.3. Research and reports…………………………………………………………….. 5
1.3.1. De Souza et al. (2019)……………………………………………… 6
1.3.2. Health Research and Educational Trust (2016)…………… 6
1.3.3. Bouldin et al. (2013)……………………………………………….. 7
1.3.4. Becker’s Healthcare (n.d.)………………………………………… 8
1.4. Importance for healthcare institutions……………………………………… 9
1.5. Benefits of the toolkit……………………………………………………………. 9
2. Practical Resources
2.1. Success and barriers……………………………………………………………… 9
2.2. Best practices……………………………………………………………………….. 9
2.3. Phases of improvement plan…………………………………………………… 9
2.4. Useful resources……………………………………………………………………. 9
3. References………………………………………………………………………………………… 10

II. Introduction
i. The problem of Patient Falls in Healthcare Institutions
Patient falls are some of the most damaging occurrences that can damage a healthcare organization’s standing in terms of patient safety and the quality of healthcare delivered. The presence of a high rate of patient falls is also an indictment on the efficiency and general quality of nursing care delivered by the nursing workforce in the healthcare institution concerned. In healthcare institutions in the United States, fall rates are between 3.3 and 11.5 falls/ 1,000 hospital stays (Bouldin et al., 2013). Although accidental falls account for a significant percentage of all falls within healthcare institutions, most of the remaining falls occur because of lack of due diligence on the part of the nurses taking care of the patients. Because of this negligence component, the Centers for Medicare and Medicaid Services (CMS) has a policy of not reimbursing for services rendered to persons who have suffered (preventable) falls in healthcare institutions (Bouldin et al., 2013). According to Morris and O’Riordan (2017), patient falls among inpatients are the most reported safety incidents even in the United Kingdom. This is to demonstrate that this patient safety issue is a universal problem which requires a generic multidisciplinary approach to solve. Institution for Healthcare Improvement.Falls are not regarded as true accidents because research has shown that most of them can be prevented with due diligence and a collaborative approach by healthcare workers. Apart from the risk of litigation for professional malpractice and the potential for a payout for damages, 30-50% of patient falls also result in some kind of physical injury to the patient. This leads to a more prolonged hospital stay, greater expenses for medical care, lost confidence in a psychological sense, and significant delays in functional recovery (Morris & O’Riordan, 2017). All these are costs which can be avoided through the provision of quality nursing care. According to the Institute of Medicine (IOM), there are six dimensions of healthcare quality. It is healthcare/ nursing care that is safe, efficient, effective, timely, patient-centered, and equitable (Prakash, 2015; Beattie et al., 2013). The presence of patient falls prevents the provision of this kind of care in healthcare institutions and is a quality gap (Unruh & Hofler, 2016).Institution for Healthcare Improvement.
ii. Why the Issue of Patient Falls is Important for Nurses
Nurses are the frontline staff when it comes to patient care in healthcare institutions. This explains why nurses are the single largest cadre of healthcare workforce in the sector. For nursing care to be considered as quality healthcare, it must lead to patient satisfaction and exceptional patient outcomes. Anything or any occurrence that may pace the patient at risk in terms of their safety leads to patient dissatisfaction and unwanted patient outcomes. As stated above, falls lead to physical injuries, increased healthcare expenditure, and prolonged hospital stays. These are not exactly desirable patient outcomes. Nurses are responsible for the safety of patients legally, ethically, and according to the professional standards of practice.Institution for Healthcare Improvement.
Legally, nurses owe patients a duty of care as the patient is under their legal and professional care. A breach of this legal duty of care (as in the case of a patient fall occurring and causing physical injury) may result in a professional malpractice suit against the nurse under whose care the patient was. According to Croke (2003), there was a 63% increase in the number of malpractice settlements made by nurses between the year 1998 and 2001 as per the National Practitioner Data Bank (NPDB). Guilt for malpractice is established by a court if professional negligence can be proven on the part of the nurse. In some cases, aside from the nurse being required to pay damages to the patient who suffered a fall and injured themselves; the healthcare institution may also be found vicariously liable for the nurse’s actions or inactions (omissions or commissions) (Al-Haijaa et al., 2018; Cooper, 2016). The nurse is expected to act the way a reasonable professional nurse in her place would act in a similar circumstance.Institution for Healthcare Improvement. What is ‘reasonable’ will be determined based on the nursing standards of practice, the institution’s policies and procedures (made known to every employee at the start of their employment contract), expert opinion, and state and federal legal frameworks. The law under which the nurse may be found guilty if a patient under their care falls and injures themselves is Tort Law; and the nurse will be found guilty of civil negligence if it can be shown that (i) a duty of care was owed the patient by the particular nurse at the time of the fall, (ii) the nurse breached this duty of care by her inability to foresee the possibility of a fall occurring, (iii) the breach of the duty of care by the nurse resulted in the injury that the patient suffered, and (iv) causation can be established beyond any reasonable doubt (Walker, 2011).Institution for Healthcare Improvement.
Ethically, the nurse is responsible for the safety of the patient under their care in all respects. This includes making sure that they do not suffer preventable falls at any time, a factor that may cause physical injury and affect both patient satisfaction and outcomes. This ethical responsibility for patient safety by the nurse is defined by the bioethical principle of nonmaleficence or primum non nocere (Santhirapala & Moonesinghe, 2016). This ethical principle basically means that at no time should the nurse engage in omissions or commissions that result in harm to the patient.
For nursing standards of practice, the registered nurse (RN) is expected to be responsible round the clock for the care and safety of the patient assigned to them. This chain of continuous care is maintained in the nursing profession by a handing over procedure that is a defining occasion for every professional nurse.Institution for Healthcare Improvement.
iii. Relevant Research and Reports on Patient Falls
Research and reports about patient falls abound in past and present literature. Apart from scores of quality improvement scholars who have carried out independent research on the quality issue of patient falls in healthcare institutions, the two organizations that have routinely produced reports on patient falls in the US are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Agency for Healthcare Research and Quality (AHRQ). Some of the research and reports on patient falls in hospitals and other healthcare institutions are as follows (de Souza et al., 2019; Health Research and Educational Trust, 2016; Bouldin et al., 2013; Becker’s Healthcare, n.d.):Institution for Healthcare Improvement.
a. De Souza et al. (2019)
This study collected data on patient falls in a hospital setting that were reported from January 2012 to December 2017 from the south of Brazil. The data was collected in January of 2018. The authors state that:
• Patient falls are the second leading cause of unintentional deaths globally
• Inpatient hospital fall rates are between 1.3 and 16.9/ 1,000 patient days
• The falls negatively impact health systems and patient outcomes in terms of reduced quality of life, prolonged hospital stay, increased hospitalization costs, and elevated mortality rates
• Hospital fall rates are underreported, meaning that the reported figures are underestimated
• The data shows that majority of the patients suffering falls were elderly and between the ages of 60 and 90 years.Institution for Healthcare Improvement.
• Most of the falls resulted in injuries such as cuts, bruises, and hematoma (De Souza et al., 2019).
b. Health Research and Educational Trust (2016)
The Health Research and Educational Trust approach to patient falls from the Joint Commission Center for Transforming Healthcare Project states that:
• Approximately 700,000 to one million patient falls occur in US hospitals annually
• Of the above falls, 30-35% of the patients sustain some form of injury as a result of the fall
• Also, out of the above falls a total number of 11,000 are fatal
• The injuries resulting from the falls increase hospital stay by an additional 6.3 hospital days
• The estimated extra cost as a result of a serious injury caused by a patient fall averages about USD 14,056 for each fallen patient
• Patient falls occur as a result of a combination of factors. Because of this, prevention strategies that are successful have always been multifaceted.Institution for Healthcare Improvement. They include a robust fall risk assessment protocol, having systems to aid healthcare staff identify patients at risk of a fall, efficient multidisciplinary staff communication concerning risk status, safe interdepartmental patient transfers, help with toileting, use of low beds with side rails, and a thorough healthcare staff and patient education program
• The Six Sigma quality monitoring paradigm is one of the most efficient quality surveillance tool that can be used to prevent patient falls in hospitals (Rastogi, 2018).
• The Centers for Medicare & Medicaid Services has identified patient falls as a preventable occurrence that should never be allowed to happen (Health Research & Educational Trust, 2016).
c. Bouldin et al. (2013)
Bouldin et al. (2013) carried out this study to collect data about patient falls before the start of the implementation of the Centers for Medicare and Medicaid Services (CMS) protocol of not reimbursing care given by hospitals to patients who have suffered injury as a result of falls in those hospitals. Data collected between July 2006 and September 2008 and available in the National Database of Nursing Quality Indicators (NDNQI) was used. The researchers state that:Institution for Healthcare Improvement.
• Rates of falls in US hospitals vary from 3.3 to 11.5 falls/ 1,000 patient days
• Approximately 25% of all the falls result in some sort of physical injury, with fractures accounting for about 2%
• A total of 315,817 patient falls occurred during the period under study at a rate of 3.56 falls per 1,000 patient days
• A total of 26.1% or 82,332 of the falls resulted in a physical injury that required care and treatment. The rate for this was 0.93 falls per 1,000 patient days
• Fall rates were highest in medical units and lowest in surgical units (Bouldin et al., 2013).
d. Becker’s Healthcare (n.d.)
According to this source, a medical-surgical unit at the Mercy Health-Anderson Hospital in the city of Cincinnati in Ohio managed to bring down its inpatient fall rate from 10 falls/ 1,000 patient days to 2 falls/ 1,000 patient days in a span of just three years. They managed to do this by using the “Transforming Care at the Bedside” or TCAB (Becker’s Healthcare, n.d.). From this success, the organization was able to identify five strategies that are effective in preventing patient falls. These are:Institution for Healthcare Improvement.
• Coming up with an easy system of identifying patients at risk of a fall
• Assigning safety companions who are tasked with continuously observing and helping the high risk patients
• Educating families in fall prevention and keeping the patient busy with constructive activities to prevent them wandering around and falling
• Setting the patient’s bed alarm to ring after just one or two seconds after a patient leaves their bed. This alerts the nursing staff who then take immediate steps to assist the patient and therefore preventing falls
• Conducting twice-a-day safety rounds by the nurses on all high-risk patients to ensure that all the fall prevention precautions are in place (Becker’s Healthcare, n.d.).
iv. The Case for Why the Issue of Patient Falls Is Important to Healthcare Institutions
The issue of patient falls is extremely important to healthcare institutions because their JCAHO rating depends on it, amongst other factors. The patient rating of the hospital also depends on its safety profile as indicated by the patient fall rate amongst other factors. To be a successful healthcare organization offering high quality and sought after healthcare services, patient falls in the organization must be kept at the most minimum level at all times.Institution for Healthcare Improvement.
v. The Benefits of Adopting the Recommendations in this Toolkit
• A single quick reference source for a quality improvement plan to prevent patient falls
• A source of data for basing quality improvement (QI) decisions on patient safety
• Better rating by patients and the JCAHO
III. Practical Resources, Tips, Suggestions, and Information for Nurses
i. Success and Barriers
• Successful organizations have a QI strategy to address patient falls
• Barriers to success include staff resistance to change and a high nurse turnover
ii. Best Practice
This means understanding that fall prevention is: (i) one of many patient priorities, (ii) balanced with the mobility needs of patients, (iii) one of many activities to ensure patient safety, (iv) unique to each patient’s needs, and (v) multidisciplinary in nature (AHRQ, 2013).
iii. Phases of a Safety Improvement Project
According to the FADE model these are focusing, analyzing, developing, and executing.Institution for Healthcare Improvement.
iv. Useful Resources
• The Agency for Healthcare Research and Quality (AHRQ)
• The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
References
Agency for Healthcare Research and Quality [AHRQ] (2013). Preventing falls in hospitals. https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk3.html
Al-Haijaa, E.A., Ayaad, O., Al-Refaay, M., & Al-Refaay, T. (2018). Malpractice: An updated concept analysis and nursing implication in developing countries. Journal of Nursing and Health Science (IOSR-JNHS), 7(1), 81-85. https://doi.org/10.9790/1959-0701078185
Beattie, M., Shepherd, A., & Howieson, B. (2013). Do the Institute of Medicine’s (IOM’s) dimensions of quality capture the current meaning of quality in health care? – An integrative review. Journal of Research in Nursing, 18(4), 288-304. http://dx.doi.org/10.1177/1744987112440568
Becker’s Healthcare (n.d.). 5 proven strategies to prevent patient falls. https://www.beckershospitalreview.com/quality/5-proven-strategies-to-prevent-patient-falls.html
Bouldin, E.D., Andresen, E.M., Dunton, N.E., Simon, M., Waters, T.M., Liu, M…. & Shorr, R.I. (2013). Falls among adult patients hospitalized in the United States: Prevalence and trends. Journal of Patient Safety, 9(1), 13–17. https://doi.org/10.1097/PTS.0b013e3182699b64
Cooper, P. J. (2016). Nursing leadership and liability: An analysis of a nursing malpractice case. Nurse Leader, 14(1), 47–51. https://doi.org/10.1016/j.mnl.2015.11.006
Croke, E.M. (2003). Nurses, negligence, and malpractice. AJN, American Journal of Nursing, 103(9), 54–63. http://dx.doi.org/10.1097/00000446-200309000-00017
De Souza, A.B., Röhsig, V., Maestri, R.N., Mutlaq, M.F.P., Lorenzini, E., Alves, B.M., Oliveira, D., & Gatto, D.C. (2019). In hospital falls of a large hospital. BMC Research Notes, 12(284), 1-3. https://doi.org/10.1186/s13104-019-4318-9
Health Research & Educational Trust (2016). Preventing patient falls: A systematic approach from the Joint Commission Center for Transforming Healthcare project. Health Research & Educational Trust. http://www.hpoe.org/Reports-HPOE/2016/preventing-patient-falls.pdf
Morris, R., & O’Riordan, S. (2017). Prevention of falls in hospital. Clinical Medicine, 17(4), 360-362. http://dx.doi.org/10.7861/clinmedicine.17-4-360
Prakash, G. (2015). Steering healthcare service delivery: A regulatory perspective. International Journal of Health Care Quality Assurance, 28(2), 173–192. http://dx.doi.org/10.1108/ijhcqa-03-2014-0036
Rastogi, A. (March 13, 2018). DMAIC – A six sigma process improvement methodology. https://www.greycampus.com/blog/quality-management/dmaic-a-six-sigma-process-improvement-methodology
Santhirapala, R., & Moonesinghe, R. (2016). Primum non nocere: Is shared decision-making the answer? Perioperative Medicine, 5(16), 1-5. https://doi.org/10.1186/s13741-016-0042-3
Unruh, L., & Hofler, R. (2016). Predictors of gaps in patient safety and quality in U.S. hospitals. Health Services Research, 51(6), 2258-2281. https://doi.org/10.1111/1475-6773.12468
Walker, R. (2011). Elements of negligence and malpractice. The Nurse Practitioner, 36(5), 9–11. http://dx.doi.org/10.1097/01.npr.0000396597.73019.45

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