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Summary C493 Leadership Learning Experience Task1.doc C-493 LEADERSHIP LEARNING EXPERIENCE TASK Falls Prevention Western Governors University Introduction The in-patient population of pediatrics is often found to trip, lose balance and fall possibly e$4.99
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Summary C493 Leadership Learning Experience Task1.doc C-493 LEADERSHIP LEARNING EXPERIENCE TASK Falls Prevention Western Governors University Introduction The in-patient population of pediatrics is often found to trip, lose balance and fall possibly e
C493 Leadership Learning Experience T C-493 LEADERSHIP LEARNING EXPERIENCE TASK Falls Prevention Western Governors University Introduction The in-patient population of pediatrics is often found to trip, lose balance and fall possibly every day. These falls especially have the possibili...
c493 leadership learning experience task1doc c 493 leadership learning experience task falls prevention western governors university introduction the in patient population of pediatrics i
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C-493
LEADERSHIP LEARNING EXPERIENCE TASK
Falls Prevention
Western Governors University
Introduction
The in-patient population of pediatrics is often found to trip, lose balance and fall possibly every
day. These falls especially have the possibility to prove fatal for the individuals. Therefore, it is
vital to implement programs to ensure the safety of our in-patient population to prevent falls
from taking place. This assignment deals with falls among the pediatric in-patient, investigating
and analyzing the problem, to thus providing a solution (prevention) for falls. The purpose of
this project is to implement falls prevention protocol within a timeline and identify the key
stakeholders in the implementation plan. Moreover, I provide a self-reflection carried out to
provide an insight into my personal role in the plan.
Section A1. Problem or Issue
The problem identified here, is falls often resulting from tripping, slipping and/or dropping
among the in-patient populations, leading them to undergo potential fatal consequences such as
mortality. Research shows that many of the in-patient population dies every year in health
organizations, due to loss of balance or dropping, which can prove to be fatal for patient
wellbeing. According to the Agency for Healthcare Research and Quality (AHRQ), up to
1,000,000 people fall in the hospital annually. Falls may result in fractures, cuts or internal
bleeding that leads to elevated health care use.
There is research to show that nearly one-third of these falls are preventable. Fall prevention
includes supervision of a patient's core fall risk causes and improving hospital’s physical design
and setting (Agency for Healthcare Research and Quality). Falls can harm the safety of the in-
patient population. My focus is to implement staff and patient/family education and equipment
to help address falls and lead to reduced numbers of falls and reduced staff injuries from patient
handling.
A1a. Explanation of Problem
The online “The Free Dictionary”, defines fall as “To lose an upright or erect position suddenly”
(The Free Dictionary). For in-patient populations, if a fall causes harm or not, each fall of our
in-patients require generation of an incident report. I have knowledge of falls causing injuries,
which have resulted in patients receiving treatment of traction, casting and surgeries for bone
fractures up to but not limited to skull fractures. These types of incidents may eventually cause
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death. Our hospital protocol prior to implementation of my program included instructing staff on
proper body mechanics when lifting/assisting bedridden or injured patients and use of antiquated
Hoyer lifts, which I observed that our staff seldom or did not use.
Since nursing school clinical, where I saw how some patients feared having staff use Hoyer lifts
with them, I have taken note of injury costs and relevant challenges of a manual patient lift
incurred in my facility, on patients and their families. Even with body mechanics teaching and
use or limited use of Hoyer lifts, our facility still saw moderate patient falls and staff injuries
related to patient handling.
A2. Investigation
I used statistics generated from incident reports on falls in our unit and literature from the
government agency, Occupational Safety and Health Administration (OSHA), while
investigating this issue. This allowed me to employ logic to understand the many approaches of
the issue related to falls and possible ways to prevent them. Further, research from OSHA
supports my investigation. According to a 2013 OSHA report, “Nearly 50 percent of injuries
and illnesses reported in 2011 among nurses and nursing support staff were musculoskeletal
disorders” (OSHA, 2013).
More exact, according to that same article, “statistics from the Bureau of Labor and Statistics
(BLS.gov) on hospital staff injuries and illnesses show that these workers incurred almost double
the national average rate. With an incident rate of 6.8 nonfatal occupational injuries and illness
per 100 full-time employees in 2011, as opposed to the 3.5/100 in every other US industry
combined. The rate of injuries of healthcare employees was quadruple that of other industries at
4.4/100 full-time employees. With almost half of these claims relating to musculoskeletal
disorders with injuries to RN being fifth” (OSHA, 2013).
When investigating the cost of effect, I found from the same OSHA report that, “In 2011, Patient
handling injuries accounted for 25 percent of all workers’ compensation claims for the healthcare
industry, with the typical claim linked to patient handling cost $15,600 and wage replacement
accounted for the major segment of this rate ($12,000). In terms of wage replacement, patient
handling injuries are among the most costly type of hospital worker injuries. Also, appraised
costs of supplanting a nurse who exits the profession, factoring in the costs related with
departure, recruiting, hiring, efficiency loss and orientation and training range of $27,000 to
$103,000 per nurse” (OSHA, 2013). For a unit my size, at that rate, in RNs alone and not
including ancillary staff, that can reach as much as $4,120,000 annually.
This issue also affects patient safety, satisfaction and recovery times when the staff injury
happens during patient handling and/or repositioning. Taking all of this into account, I realized a
need to implement proper training of management, staff and patients through fall prevention
education to avoid such incidences in our organization.
A2a. Evidence of Problem
To evidence the problem of patient falls, through the process of collecting evidence from my
work unit, I collected relevant data from physician preference surveys, annual hospital falls
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statistics for my unit and hospital policy for using the Hoyer lift. I also used informal interviews
of ancillary staff, nurses, management and other relevant staff.
I found that in 2016, our 24-bed floor had 14 reported falls incident reports on file. That our
staff has not used the Hoyer lift on our floor or did not know that our unit had one for use. I was
unable to find hospital policy for using the Hoyer. The physicians/surgeons preference was that
RN use their specific orders for generating a care plan relating to patient handling of
incapacitated or surgical patients. Management wants to reduce the number of falls on the unit
as well as wants to reduce the number day staff loses due to injuries and associated costs for
employee absences due to fall related injuries. This boosted my enthusiasm to implement a
change for preventing falls.
A3. Analysis
In this project, I had to assume the role of scientist, detective and manager of healing
environment. Resultant of this, as a professional nurse, my personal analysis for falls prevention
after all of these processes, I concluded that implementing staff and patient/family education on
preventing falls and induction of advance patient lifts (Sara Stedy) will be an effective solution
to avoiding injuries and additional cost related to in-patient falls.
My analysis of the investigation findings shows that the main reasons behind these falls were the
carelessness on behalf of the organizational staff due to lack of prevention education, along with
a lack of a proper alert system like proper signage indicating patient fall risk for staff, etc. within
the organization. Being in a new or strange environment like a hospital can be foreign to our
pediatric population and their families leading to anxiety and fear. Our system, as a responsible
party, needs a way to assist our patients with becoming familiar with their new surroundings and
educate them on safety procedures while in the hospital.
According to Kalisch, Tschannen & Lee (2012) most patients are highly anxious about
administration of medical drugs, which can potentially lead to dizziness, drowsiness, etc. This
along with their degeneration of other health ailments prevents them from seeing things properly
increasing their fall-risk chances. These along with the lack of proper alert signs in the
organization due to lack of prevention education lead to accidental falls which have resulted in
the 42% of bone fractures and 2% of head trauma cases (Ackley, Ladwig & Makic, 2016).
A3a. Areas Contributing to the Problem or issue
I found three key areas, which I identified here causing the falls. These include, but is not
limited to the medication provided to patients, the lack of proper alert system, be it in corridors
or within the care units or wards of our organization, along with lack of proper education of staff
members. According to Wold (2013), antiepileptic medication, along with those administered for
diabetes and cardiovascular health problems, etc. can behave as sedatives, which decreased their
already low awareness increasing their fall-risk.
This along with the lack of proper alert system when going to bathrooms, along with lack of
proper lighting in rooms lead to patient falls. These have been further found to be increased as
per Hamric et al. (2013) due to lack of proper fall prevention education among staff and
management, leading to carelessness on their behalf in their quality of health services provided
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