Running head: QUALITY IMPROVEMENT: PATIENT FALLS

Quality Improvement: Patient Falls

Jessica Organt
Bon Secours Memorial College of Nursing
Quality and Safety in Nursing II
NUR 3207
Professor Tomeka Dowling
April 25, 2015

I pledge
Quality Improvement: Patient Falls
When attempting to come up with a problem identified in the field of nursing, many ideas
came to mind for the author. However, the author has chosen to discuss a problem that was
identified at their facility of work that has been an area of focus for quality improvement projects
year after year. Every year, the authors facility, as well as facilities nationwide, focus their
attention on reducing patient falls in the hospital. It seems, though, that year after year, fall
reduction is brought up again for quality improvement projects after having the issue continue
even after the quality improvement project has been completed.

Falls are common adverse events in hospitals and can result in significant injuries.
Reported fall rates for hospital inpatients range from 1.7 to 25 per 1000 patient days, depending
on the patient care area, with 6% to 44% resulting in injury. Injurious falls are associated with
increased health care costs, longer hospital stays, and greater likelihood of discharge to a nursing
home or rehabilitation facility (ONeil et al., 2015, p. 1). Falls are associated with increased
risks of mortality and morbidity, with an estimated cost of $20 billion per year (Spiva et al.,
2014, p. 164). So what can be done to improve patient fall ratios and overall patient safety? If a
Quality Improvement Project were to be implemented to help improve patient outcomes by
reducing patient falls, many quality and safety care standards would need to be considered.
Implementing a Quality Improvement Project, the author would use the Plan Do Study
Act (PDSA) model. For the first step of the model, plan, the author would set the goal and plan
for the overall project itself. The plan would be to decrease the number of patient falls by half on
a geriatric MedSurg unit at the VA hospital by January 2016. This plan is a SMART goal
(specific, measurable, attainable, relevant and time specific) and identifies the patient population,
the time frame, a measurable goal, relevance and it is realistic. Also in the planning stage, any
roadblocks to attaining this goal would be listed.
The next step of the Quality Improvement Project in the PDSA model is do. In this step,
the author would begin to carry out the plans discussed to achieve the goal of lowering patient
falls. The author could give an in-service to the staff members of the floor including education
for the nurses on the policies of the floor. The nurses could be educated on the Morse Fall risk
assessments, the documentation involved post fall, the changes needed in staffing to maintain a
safe nurse to patient ratio, and proper training on all equipment involved in patient transport and
transfer. In doing so, it is critical to understand what quality and safety care standards would

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need to be in place before this goal can be reached.

One of the first quality and safety care standards that need to be in place with a quality
improvement project focused on falls is a guideline and policy for adequate staffing and nurse to
patient ratios. Aside from showing that improved staffing can help decrease the number of
patient falls, increased staffing has also been shown to reduce rates of mortality and failure to
rescue (Everhart et al., 2014). Aside from coming up with a policy for adequate staffing,
enforcing the new policy is equally important. Many times nurses come into work to find out a
coworker has called out. The nurse to patient ratio would have been four to one, however now
that someone has called out, the staffing is now six to one in a very heavy MedSurg population,
high in geriatrics. Although the nurses may work together to get the work done, medications
passed, and charting done; patient safety may be compromised. Because nurses are being pulled
in different directions and are spread more thin, patients may not be monitored as closely as they
should be and may result in a patient who tries to get up out of bed alone without help, or calls
on the call bell but doesnt get an answer fast enough and gets out of bed alone, and ultimately
falls.
Another quality and safety standard that must be enforced to decrease falls is proper
education and assessments. Nurses need to be educated on what questions should flag the nurses
attention to make the patient a fall risk. When a patient is admitted into the hospital, nurses
should complete a full assessment of the patient, as well as a full history of falls, particularly if
the patient has had any within the last three months, or if the patient has had any falls with injury
(Christopher, Trotta, Yoho, Strong, & Dubendorf, 2014). Proper assessments and documentation
alert not only the nurse working with the patient currently, but also anyone who may be caring
for the patient. Once the patient has been identified as a high fall risk, the proper identifiers are

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placed on the patients room, chart and wrist band to alert all other nurses and nursing assistants
and anyone else who may come into contact with the patient. Without proper assessment and
documentation, however, patients who are high fall risks may not be monitored as closely as they
should be, and may fall while in the hospital.
Along with the proper assessment and education of the nurses in identifying high fall risk
patients, nurses and staff also need education on what interventions are needed when a patient is
in fact, a high fall risk. All members of the care team need to be properly educated on the
interventions needed to decrease falls on the unit. Team training and in-services have shown to
be an effective way to reduce falls and patient harm while in the acute care setting, as well as
promoting a culture of safety and teamwork (Spiva et al., 2014). Policies need to be written
including all interventions such as moving the patient closer to the nurses station, ensuring
patients always have their call bells and personal items within reach, that patients are educated
on how to use the call bell, all patients are wearing non-skid socks, and bed alarms are turned on
with all high fall risk patients. Nurses also need the proper education and training on the use of
bed alarms for patients who are high risk for falls. Recently, the authors facility just received
new bed alarms, and received no training on them. Many of the nurses believed they had the bed
alarm on the highest sensitivity, when in reality, the alarm was set only to go off once the patient
was out of the bed, which was too late to help decrease falls. If the staff had been properly
trained and educated on the equipment, the number of falls could have been reduced. Along with
bed alarms, nurses and staff need to be educated on the available tools and safe use for all
equipment, including lifts and transfer equipment. When the staff know not only how but also
when certain equipment is appropriate, patients are less likely to fall.
Another quality and safety standard that must be implemented to help reduce patient falls

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is bedside rounding with a purpose. Rounding with a purpose, or intentional rounding, focuses
on the five Ps; potty, position, pain, possessions and patient focus (Patterson, 2014). Evidence
shows that rounding with a purpose, assessing the patients bathroom needs, pain, positioning in
the bed, ensuring they have all their possessions in reach, and patient focus has shown to increase
pain control efficacy, patient satisfaction, decreasing pressure ulcers and decreasing falls
(Patterson, 2014).
Lastly, a final suggestion for a quality and safety care standard that would help reach the
goal in the Quality Improvement project focusing on reducing falls in the hospitals would be
mandating that all patients have a medication reconciliation completed by a pharmacist and
physician upon arrival to the hospital, and anytime a new medication is added. Many times
medications are added to the patients regimen, disregarding all other medications the patient
may be on, and in turn, the patient may have drug interactions that could cause confusion,
delirium or worse. Medications known to increase the risk for falls should be used sparingly, and
only when absolutely needed. There is a very strong correlation between falls and medications
such as antidepressants, benzodiazepines and antihypertensives. Multiple medications can also
contribute to delirium, also increasing the risk for falls (Davies & OMahoney, 2015).
Once all of the pieces have been implemented, the next step in the Quality Improvement
project would be to study what results have been seen since implementing the changes. After
nurses have been provided education on the proper assessments, documentation and assistive
devices, policies have been written to define safe staffing and ratios, intentional hourly
rounding has been implemented and full medication reconciliations are completed upon every
admission, the Quality Improvement team would then need to focus on all results obtained in the
study. Did implementing these changes reduce patient falls? Did the project reach their goal of

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reducing patient falls by half or did they reduce falls at all? In this step, it is also important to
summarize everything that was learned during the study. It is hopeful that the implementation of
all the steps in the project have helped reduce the number of patient falls significantly. If not, and
patient falls have either increased or not decreased at all, the project would need to be reevaluated with a possible new goal in mind and new steps to obtain this goal need to be
determined.
Implementing the project with the interventions listed above can help to not only reduce
patient falls and increase patient satisfaction, but also improve nurse satisfaction as well. By
creating a policy to set standards on nurse to patient ratios, it ensures each nurse that they will
have the proper support and assistance needed to safely care for their patients on a daily basis.
Nurses will have a higher satisfaction with their job, and nurses will be more than likely to stay
on their floor with less of a turnover. In doing so, there becomes a larger pool of educated and
more experienced nurses, also increasing patient safety.
When nurses are educated on the tools and resources they have available to them to assist
with patient transport and transfer, patients will feel well supported and safe while the nurses will
be less frustrated with the constant heavy lifting of patients. Often times, the geriatric population
has a hard time coming to terms with the loss of independence, and educating the nurses on the
equipment available not only ensures safe patient transfers, but also can work to provide the
patient with a sense of independence, allowing them to help as much as possible. Intentional
hourly rounding has already been shown to help decrease falls and increase patient satisfaction,
but when combined with the other interventions listed, patient satisfaction is sure to improve.
Patients will see that their specific needs will be addressed hourly, as well as knowing that they
are being monitored closely, including having their medications reviewed with them regularly.

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Many of the patients on the geriatric ward have a form of dementia, and seeing the nurse more
frequently can help reduce anxiety and stress for the patient.
The Quality Improvement Project focused on patient falls can bring many improvements
to the unit, to the nurses and patients separately and also together. There have been several ideas
shown that have proven to help reduce patient falls, and applying that knowledge to the project
ensures that patient falls will decrease. Educating the nurses, implementing hourly rounds with a
purpose, medication reviews and proper staffing can bring great changes to any unit and can
ultimately reduce patient falls and injuries.

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References
Christopher, D. A., Trotta, R. L., Yoho, M. A., Strong, J., & Dubendorf, P. (2014). Using process
improvement methodology to address the complex issue of falls in the inpatient setting.
Journal of Nursing Care Quality, 29(3), 204-214.
http://dx.doi.org/10.1097/NCQ.0000000000000053
Everhart, D., Schumacher, J. R., Duncan, R. P., Hall, A. G., Neff, D. F., & Shorr, R. I. (2014).
Determinants of hospital fall rate trajectory groups: A longitudinal assessment of nurse
staffing and organizational characteristics. Health Care Management Review, 352-360.
http://dx.doi.org/10.1097/HMR.0000000000000013
ONeil, C. A., Krauss, M. J., Bettale, J., Kessels, A., Costantinou, E., Dunagan, W. C., & Fraser,
V. J. (2015). Medications and patient characteristics associated with falling in the
hospital. Journal of Patient Safety, 1-7. Retrieved from http://ovidsp.tx.ovid.com/
Patterson, L. M. (2014). Preparing staff for intentional rounding. Journal for Nurses in
Professional Development, 30(1), 16-20.
http://dx.doi.org/10.1097/NND.0000000000000026
Spiva, L., Robertson, B., Delk, M. L., Patrick, S., Kimrey, M. M., Green, B., & Gallagher, E.
(2014). Effectiveness of team training on fall prevention. Journal of Nursing Care
Quality, 29(2), 164-173. http://dx.doi.org/10.1097/NCQ.0b013e3182a98247