Patient safety

IPSG 6

“Reduce the Risk of Patient Harm Resulting from Falls”

By: Group 4

Dian Afdianti 1311312026

Jamilatur Rasyidah E. 1311312018
Sonia Mestika .H. 1311311053

Undergraduate Nursing Program

Faculty of Nursing
2014
 Foreword

Praise and thankfullness stated to almighty ALLAH SWT, has given the great chance and
oppurtinity to the writer team for finishing this paper well. The tittle of this paper is about "The
Patient Identify".
The purpose of this paper to make students undertand having a good knowledge and skill.Then,
students can practice to the patient at all.
The writer team also say thanks to Mss. Vetty Prisilla. And all of our family that had given us
many support and contributions to writing this paper.
The writer team really realizes this paper was not written maximally and perfectly, therefore the
team also hopes some improving suggestion and critics from all the readers, the writer team will
appreciate it.

Padang,Mei 12th, 2015

The writer team

 Chapter I
Introduction

Many injuries in hospitals to both inpatients and outpatients are a result of falls. The risk
for falls is related to the patient, the situation, and/or the location. Risks associated with patients
might include patient history of falls, medications use, alcohol consumption, gait or balance
disturbances, visual impairments, altered mental status, and the like. Patients who have been
initially assessed to be at low risk for falls may suddenly become at high risk. Reasons include,
but are not limited to, surgery and/or anesthesia, sudden changes in patient condition, and
adjustment in medications. In the Mater Private, patients are assessed and periodically reassessed
depending on each patient’s risk for falling, including the potential risk associated with the
patient’s medication regimen and health status, and take action to decrease or eliminate any
identified risks.
 Chapter II
Literarature Review

A. INTERNATIONAL PATIENT SAFETY GOALS

The International Patient Safety Goals (IPSG) promote specific improvements in patient
safety. The goals highlight the most common problems in health care and provide support with
simple, effective solutions. The Mater Private is committed to following the advice and
recommendations of the International Patient Safety Goals and we have put many measures in
place to ensure we provide safe care.
The goals of patient safety are:
1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of High-alert Medications
4. Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery
5. Reduce the Risk of Health Care Acquired Infections
6. Reduce the Risk of Patient Harm Resulting from Falls

B. SIXTH GOAL PATIENT SAFETY : REDUCE THE RISK OF PATIENT HARM

RESULTING FROM FALLS

Falls are big problem in hospitals. Patient falling is the most common patient safety incident
reported to National Patient Safety Agency of the UK.1 Falls can cause very serious injury and
even death. They may delay hospital discharge with high costs to the patient and the hospital.
There may initiate litigation against the organization. Obviously, healthcare workers must prevent
falls and the harm that they can lead to.

Often events occur in our hospital that, although unfortunate, propel our team of dedicated
Beaumont employees to work together to provide a comprehensive solution. Such events include
patient falls, which have been analyzed for commonalities, as well as opportunities for
improvement.

Our nursing leadership took the reins and employed the assistance of all those who touch patients'
lives. A large, multidisciplinary team was put together to determine some of the causes of patient
falls and make recommendations on how they could be prevented. The goal was to engage all
members of the Beaumont team to become active participants in patients' safety.

To eliminate the potential for falls, the team came up with the following recommendations and
strategies to ensure our patients' safety:

 Empower our nursing assistants as patient advocates. This includes having nurses conduct
rounds in the patient care areas to promote an active dialogue, as well as authorizing the
nursing assistants to initiate the fall-prevention program for patients seen as high risk.
 Promoting a proactive approach to toileting patients (after the pilot program was so
successful). Additionally, as a result of a nursing research project, patients' slippers have
been changed to a new "safety slipper" that has non-skid tread on both top and bottom.
 In terms of staff education, the Relationship Results-Oriented Health Care (RROHC)
sessions continue. These sessions focus on enhancing communication between nurses and
patients.
 Implementation of the Start from the Heart (mobility program) was conducted with staff
from physical therapy. There was also a wound care fair, which demonstrated the safety
features of some of the beds within our facility.
 Matching fall-prevention options with the variety of beds we have has proved useful for
both staff and the safety of our patients.

Keeping the patient at the center of all we do is vital in keeping our patients safe. Providing the
highest quality of care to our patients aligns with one of Beaumont's core values - Everything we
do is for the benefit of the patient.

Patient Falls

Patients are often in a weakened or confused state in hospital, and are more susceptible to falling.
Falls are a leading cause of hospital-acquired injury, and frequently prolong or complicate hospital
stays. At Healthscope hospitals we document and investigate every fall and take action to reduce
the number of falls that occur.

This graph shows the number of falls in Healthscope hospitals for the past 6 years, compared with
the industry rate. Falls are presented as a percentage of patient days – allowing us to compare
Healthscope hospitals with other hospitals of a different size. Patients in Healthscope hospitals on
average have a lower rate of falls than those in other hospitals.

*In January 2015, an external audit found an inconsistency in hospital data for 2013. As a result,
the chart has been revised and the rate has increased.

WHY DO PATIENTS FALL?

Patients can fall as a result of multitude of reasons:
 Age: Older patients are more prone for fall than young ones.
 Poor vision: Patients may not be able to see well, can trip over things they cannot see.
 Confusion: Confused patients may not pay attention to dangers. They may try to stand up
when their muscle are too weak; they may fall down stairs, and they may try to walk to the
bathroom in a dark room without calling for help.
  Some medications: Many patients fall because they are taking a medication that makes
them sleepy or dizzy. Others may fall from medications that lower blood pressure when
they stand (postural hypotension).
 Poor balance, coordination, gait and range of motion (ROM): A person will fall when they
can’t keep their balance. Many older patients and those that have had a stroke have poor
balance and poor gait and coordination.
 Weak muscles: People that have weak muscles or damaged nerves will fall if help, safety
and good patient care are lacking.
 Disease conditions: Such as arthritis, stroke, Parkinson’s disease, heart disease, and
seizures.
 Surrounding factors: Rooms that have clutter, poor light or have no nurse call bell are not
safe. They can make a person fall or trip. Glare also adds to falls.
 Patient foot wear: Shoes and slippers that are not skid proof are a danger. All patients
must have sturdy, skid proof shoes or slippers that fit well.
 No answers to calls for help: Calls for help must be answered right away. A nursing
assistant or nurse must go to the patient room right away when a patient calls for help
and/or turns on their nurse call bell. This is important if the person is at risk for falls.
 Broken equipment. Broken cane, walker, wheelchair or malfunctioning wheelchair brake
can make a person fall.

What we are doing to further reduce falls

Reducing the risk of patient harm resulting from falls is one of the patient safety goals of the
Australian Commission on Safety & Quality in Healthcare (ACSQHC) . Healthscope has a falls-
reduction program that provides guidelines for everyone involved in the care of patients in all of
our hospitals. The falls-reduction program includes patient evaluation, interventions, staff
education and training, patient education and outcomes assessment.

Improvement strategies may vary from hospital to hospital. Examples are:

 Assessment of all patients for risk of falls

  Implementation of precautions to reduce the risk of falling for example:
- Non-slipsocks
- Bed and chair sensors which detect patient moving from bed
- Use of lifting equipment and walking aids
 Analysis of falls incidents
 Spot audits to provide information about environmental factors
 Use of a “traffic light” system where patients are given a red, orange or green tag, which
alerts staff to whether the patient is at risk of falling

How to Prevent Falls?

If the patient is at risk of fall, a fall risk sign should be placed on the patient’s room entrance
or at the bed if more than one patient shares a single room. Patients at risk of fall may be positioned
in rooms closer to the nursing stations and have nurse-call buttons and alarms handy and
functioning.
Other special fall risk care items, measures, and precautions should be in the care plan for
fall risk patients such as:
 Low beds
 Changing the patient’s medications, when possible, to lower the risk of dizziness,
sleepiness and/or blood pressure changes.
 Regular patient monitoring and observation
 Using protective, gym type, mats on the floor next to the bed to lower the risk and
extent of injury if a patient falls
 Balance, gait, muscle and/or range of motion exercises and training
 Assistive devices, such as canes, walkers and Merry Walkers
 High toilet seats

All patients must have a safe room and patient care area that is:
 Well lit and with no glare
 Kept clean, dry and uncluttered
 Skid proof and dry
 Sturdy, non skid shoes and footwear
  Equipped with handrails and grab bars,especially in the bathrooms and in areas where
patients walk, like the hallways
 Filled with stable and sturdy chairs at a good height and with armrests to assist the
patient or resident with standing
 Free of wires, cords and other tripping hazards
 Free of side rails and restraints

 Tips to prevent falls

1. Use the call light when you need help.
2. Ask the nursing staff for help to and from the bathroom. This is very important if
you are unsteady. The call light in the bathroom may be located on the wall.
3. For your safety, a member of the nursing staff may stay with you in the bathroom.
4. If you take medicines that cause you to go to the bathroom often, ask for help when
you need to get up. Consider using a commode or urinal.
5. Some medicines may cause you to feel dizzy or sleepy. Take your time getting out
of the bed or chair. Sit at the edge of the bed for a few seconds before you get up.
6. Wear nonslip footwear or slippers when you are up.
7. Wear your eyeglasses and/or hearing aid(s) when you are awake.
8. Walkers and canes can provide support. Other items do not. Do not lean on the
bedside table, furniture, IV pole or other items to steady yourself.
9. Ask a member of your health care team to place the call light, phone and personal
items within your reach before he or she leaves the room.
10. Tell a member of the nursing staff if you have any concerns about your safety.

 Tips for family and friends

The nurse identifies patients who may be at risk for falling with red slippers and/or special
signs. Please speak up about safety concerns to the nursing staff. This includes information
about the risk of falling, or a recent history of a fall.
Patient safety and comfort are important to the health care team. Family and friends can
also help. Please read the information in this fact sheet so you can remind your family
member or friend of the 10 tips to prevent falls.

You can also do the following.

11. Make sure the call light, phone and personal items are within easy reach of the
patient before you leave the room.
12. Call the nurse if the patient is weak or lightheaded.
13. Consider staying with the patient if he or she is confused or at a high risk of
falling.
14. Call the nurse before leaving the patient if he or she is confused.
15. Remind the patient to ask the nursing staff for help when getting up.
 Chapter III
Conclusion

Falls are big problem in hospitals. Falls can cause very serious injury and even death. They
may delay hospital discharge with high costs to the patient and the hospital. Obviously, healthcare
workers must prevent falls and the harm that they can lead to.
All admitted patients are at risk of falling due to different causes. Preventing falls is
a team effort. All healthcare workers taking care of patients must make sure that their patients are
safe. The organization implements a process for the initial assessment of patients for fall risk and
reassessment of patients when indicated by a change in condition or medications, among others.
Measures are implemented to reduce fall risk for those assessed to be at risk. Measures are
monitored for results, both successful fall injury reduction and any unintended related
consequences. Policies and/or procedures support continued reduction of risk of patient harm
resulting from falls in the organization.
Resource :
- National Patient Safety Agency (2007). The Third Report from the Patient Safety observatory:
Slips, trips and falls in hospitals.
- Allina Health's Patient Education Department, Ten Tips to Prevent Falls While You Are in the
Hospital, safe-ahc-12197
- http://www.healthscopehospitals.com.au/index.php/myhealthscope/patient-falls/
- http://www.beaumont.edu/quality-care/improvement-programs/Reducing-Patient-Falls/
- https://www.materprivate.ie/about-us/patient-safety/international-patient-safety-goals/