National Patient Safety Goals

Presented by: Wendie Do, Racquel Galang, Rebekah Shim

Date: October 11, 2017
Course: UNRS 403 Leadership & Management in Professional Practice
Instructor: Professor Melissa Muddell
Statistics
Every year in the United States, hundreds of thousands of patients fall in
hospitals, with 30-50 percent resulting in injury.

Injured patients require additional treatment and sometimes prolonged hospital

stays. In one study, a fall with injury added 6.3 days to the hospital stay.

The average cost for a fall with injury is about $14,000

((The Joint Commission, 2015)

 Goal 9 : National Patient Safety Goal
NPSG.09.02.01
Reduce the risk of patient and resident harm
resulting from falls.

(The Joint Commission, 2015)

Rationale
Falls are the most significant portion of injuries in hospitalized settings. The
organization should evaluate the patients or residents risk for falls and take
action to reduce the risk of falling and the risk of injury. The evaluation includes a
patients or residents fall history; review of medications and alcohol consumption;
gait and balance screening; assessment of walking aids, assistive technologies,
and protective devices; and environmental assessments.

( The Joint Commission, 2015)

Common Contributing Factors to Falls
Analysis of falls with injury in the Sentinel Event database reveals the most common
contributing factors pertain to:

Inadequate assessment

Communication failures

Lack of adherence to protocols and safety practices

Inadequate staff orientation, supervision, staffing levels or skill mix

Deficiencies in the physical environment

Lack of leadership (The Joint Commission, 2015)

Fall Assessment/Investigation
Before the fall:
-Any pre-syncopal symptoms? (dizziness, palpitations, feeling light-headed)
-What were they doing? (getting up, in the middle of walking, using the toilet)
-How is their general health?
-How do they usually get around?

During the fall:

-Do they remember falling?
-Was it witnessed?
-If not, assume there might have been LOC.
-If it was, obtain a detailed collateral history
-Did they have loss of consciousness?

(Oxford Medical Education, 2015)

Review of Medications/Substance-use
Medications that can contribute to falls or increase the risk of
injury from falls:
-Anti-hypertensives postural hypotension
-Anti-hyperglycemics can cause hypoglycemic events
-Analgesics underuse can lead to poor pain control which
can impair mobility, and side-effects can include drowsiness
-Diuretics increased urinary frequency and incontinence
-Anti-epileptics
-Anti-coagulants increased risk of bleeding
-Psychotropics

Substances:
-Alcohol, illicit drugs
(Oxford Medical Education, 2015)
Gait and Balance Screening
Components:

-Lower extremity examination

-Focus is on mechanical issues
-Complete neurologic assessment
-Muscle weakness, Impaired proprioception, Cerebellar signs
-Evidence of stroke, peripheral neuropathy
-Functional assessment
-How the person sits, stands, walks, and turns
-Any aids?

(Williams & Gentili, 2009)

 Morse Fall Scale

Scoring:
0: No risk for falls
<25: Low Risk
25-45: Moderate Risk
>45: High Risk

(U.S. Department of Health and Human Services, 2009)

Use of Assistive Devices
Consider assistive devices when evaluating extrinsic risk factors that can cause
accidental falls.

Canes, walkers, and wheelchairs are meant to increase the patients support
and improve balance and mobility.

But many patients arent properly taught how to use them

Or the device is damaged or the wrong size for the patient.

In long-term care facilities, the highest incidence of falls occurs during

transferswhen the patient moves from wheelchair to bed or gets up from an
unbraked wheelchair. (Quigley, 2015)
Environmental Assessments
Accidental falls can result from an unsafe environment or environmental risk
factors.To reduce risk of falls maintain a constant awareness of environmental
safety.

Eliminate slipping and tripping hazards.

Keep the bed at the proper height during transfer

Use proper room lighting.

Check chairs, toilets, and safety grab bars for potential safety problems

Make sure the patient wears proper footwear

(Quigley,(not just nonskid socks)
2015)
 References
Oxford Medical Education (2015). Falls assessment and management. Retrieved from
http://www.oxfordmedicaleducation.com/geriatrics/falls-assessment-management/

Quigley, P., (2015). Focus on...FALLS prevention. American Nurse Today, 10(7), 27-39.

The Joint Commission (2015). National Patient Safety Goals Effective January 1, 2015: Nursing Care
Center Accreditation Program. Retrieved from
http://www.jointcommission.org/assets/1/6/2015_NPSG_NCC.pdf

The Joint Commission (2015). Sentinel Event Alert 55: Preventing falls and fall-related injuries in health
care facilities. Sentinel Event Alert, 55. 1-5.

U.S. Department of Health and Human Services (2013). Preventing falls in hospitals. Retrieved from
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3h.html

Williams, M. E. & Gentili, A. (2009). Assessment of the the geriatric patient: Gait and balance. Medscape.
Retrieved from http://www.medscape.com/viewarticle/712260