Safety Performance Improvement Paper: Falls and Fall Preventions

NURS 490W- Nursing Leadership

Purpose of Assignment
To identify a safety issue within a health care organization that needs to change in order to
promote better delivery of patient care; to demonstrate an ability to collaboratively problem-
solve in an interdisciplinary environment while working towards resolution of a common
problem.
Student Approach to Assignment
I approached this assignment by thinking about a common issue in my workplace. Falls are a
common issue with patients and preventing falls is extremely important in any healthcare
specialty.
Reason for Inclusion of this Assignment in the Portfolio
I included this in my portfolio because it demonstrates my competence in effective care
planning techniques and my ability to acknowledge safety precautions to prevent falls. This is
important because patient falls are a major problem in the healthcare community and measures
should be taken to prevent as many as possible.

• Critical Thinking
o Engages in creative problem solving
I researched and assessed numerous interventions to prevent falls such as hourly
rounding, bed in the lowest position, making sure the call bell is within reach and
educating the patient to call for help and how to use their call bell. I also
discussed the use of alarm pads for use in chairs or beds to alert the staff to a
confused patient attempting to stand without help.
o Evaluates nursing care outcomes through the acquisition of data and the questioning of
inconsistencies
I examined studies performed regarding fall preventions including one in the
Boston, MA area regarding the fall prevention tool kit (FPTK) and according to
the results it can potentially prevent 1 fall every 4 days, 7.5 falls each month, and
approximately 90 falls a year. I also identified a study by Johnson et al., 77% of
falls were unwitnessed because patients failed to seek help when moving in bed or
ambulating to the bathroom even when educated to do so.
Teaching
o Uses information technologies to communicate health promotion, risk reduction,
and disease prevention.
o I used the Old Dominion web library to access multiple electronic articles,
journal articles and verified sites to identify statistics on fall risks and
prevention methods to present to my group and class. I used these
electronic materials to research the frequency of falls, prevention
techniques and outcomes of interventions.
Nursing Practice
o Establishes and/or utilizes outcomes measures to evaluate the effectiveness of
care.
o Not only did I utilize research studies regarding fall prevention but I also
researched measures to implement change within a facility using the
change theory of nursing by Kurt Lewin. Studies have been conducted
that have shown the use of "safety huddles" by clinical teams that
describe the current status of the patient and attempt to identify clinical
and non-clinical opportunities to improve patient safety. It has been
shown that since the use of safety huddles in some hospitals, the rate of
falls in some hospitals has decreased