Running head: FALL ANALYSIS

Leadership Strategy Fall Analysis

Staci Mason, Elizabeth Mitchell, Leslie Rush, Bridgett Weldon
Ferris State University

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Abstract

The quality improvement process is very important for nurses to understand and utilize within
their facility to help address issues, especially those which involve patient safety. Fall prevention
strategies have been put into place in many facilities to help address this important patient safety
issue. In the following, a fall prevention program will be discussed. The need for fall prevention
programs, an interdisciplinary team formation, data collection methods, outcomes,
implementation strategies, and an evaluation will be addressed.

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Leadership Strategy Fall Analysis

Preventing falls in the hospital setting is important for patient safety, staff safety, and
hospital costs. Falls occur at higher rates in geriatric units, which unfortunately are also the
patient population whom have the hardest time recovering from a major injury (Williams,
Szekendi, & Thomas, 2014). This quality improvement analysis will focus on preventing
inpatient falls in geriatric units. Analyzing clinical need, forming an interdisciplinary team, data
collection, outcomes, implementation, and evaluation will be discussed in the following. By
implementing a fall prevention strategic plan, the interdisciplinary team will help prevent falls
and their complications in the geriatric population.
Clinical Need for Fall Prevention Practices
It has been found that a well-planned and implemented fall risk prevention program can
decrease the patient fall rate by up to 64% (Williams, Szekendi, & Thomas, 2014). The Joint
Commission stresses the importance of reducing falls and harm from falls in their National
Patient Safety Goals (2008). The factors that The Joint Commission recommends reviewing
when developing a plan to prevent patient falls are an environmental assessment, individual
assessment, and medication regime (2008). There are many factors that increase the risk of a fall,
which makes preventing falls in the hospital setting challenging. A patient is at increased risk of
a serious injury from a fall with any of the following risk factors; history of a recent fall,
advanced age, certain medications, altered mental status/impaired cognition, specific diagnoses,
multiple comorbidities, mobility impairment, muscle weakness, postural hypotension, behavioral
disturbance, agitation, and urinary incontinence or frequency (Williams, Szekendi, & Thomas,
2014, p. 19).

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While geriatric units have fall prevention methods in place, falls continue to happen at an
alarming rate. A fall risk assessment must be in place and in use in the hospital setting (The Joint
Commission, 2008). This assessment was first introduced in 2005 and between 2005 and 2010
the fall rate decreased by 20% (Williams, Szekendi, & Thomas, 2014, p. 20). This shows how a
fall prevention program can help decrease falls in the hospital setting. In the geriatric population,
in particular, facilities that had higher compliance with fall risk, and more knowledgeable staff
members showed significantly less patient falls in 1000 patient stay days (Colon-Emeric, 2013).
These findings support the need for a fall prevention program in the geriatric population.
Interdisciplinary Team
The interdisciplinary team will consist of an RN falls champion, physical therapists,
occupational therapists, unlicensed assistive personal, housekeeping, and a pharmacist. Each
team member will give input into the patient risk of having a fall, or the risk of injury should a
patient fall.
Registered Nurse (RN)
The nurse is the primary caregiver of the geriatric patient. He/she will be responsible to
provide an initial fall risk assessment based on patient cognition, mobility status, medications,
and environmental risks. If a patient is identified as a risk, then it is the nurses responsibility to
ensure that the hospitals fall protocols are implemented to keep the patient safe and to consult
other members of the team. He/she will also track patient falls on the unit and what could have
been done to prevent them.
Physical/Occupational Therapy (PT/OT)
Physical and Occupational therapy are responsible for assessing the patients strength,
mobility, and possible needs at home, steering them to recommendations for outpatient care once

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the patient has been discharged. Therapy is intended to teach the patient proper techniques for:
getting up, using assistive devices for walking, having safe mobility at home.
Unlicensed Assistive Personal (UAP)
UAP's are responsible for knowing what fall risk prevention methods have been
established. It is the nurses responsibility to relay this information to the UAP. If the
information is not relayed, the UAP must find out before providing patient care.
Housekeeping
The housekeeping crew is responsible for cleaning each patient room and the assigned
unit. Housekeeping is accountable for marking areas on the floor that are wet, to help prevent
slips and falls. They actively help to reduce the clutter in the room by sweeping and removing
unnecessary items.
Pharmacist
The pharmacist is in charge of reviewing all medications and medication interactions to
make sure the patient is getting the correct medication and dose. He/she will review the list of
medications a patient is taking to determine if the patient may be at risk for a fall by becoming
dizzy or hypotensive.
The above listed team will work together to form a proper fall risk assessment to include
information about mobility, medications, and future needs. Communication will be priority in
preventing falls for geriatric patients.
Data Collection Method
With the help of the interdisciplinary team members collaboration, data is collected. By
using specific tools, data can be collected and analyzed concerning falls to develop a successful
fall prevention program. There are many tools that can be used to organize and present data.

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Some examples are bar graphs, flowcharts, and fishbone diagrams. (Yoder-Wise, 2014). Since
supportive data is needed to assist in gathering and preventing future falls with patients, a
fishbone diagram will be considered useful and relevant in this case. According to Yoder-Wise
(2014), a fishbone diagram is an effective method of summarizing a brainstorming session. A
specific problem or outcome is written on the horizontal line. All possible causes of the problem
or strategies to meet the outcome are written in a fishbone pattern (p. 398). Examples can be
found from the data collected, such as occurrences leading up to a fall. These will help to
identify causes leading to a proper resolution. The data that is collected by the interdisciplinary
team members regarding the reasons for falls and if they were preventable will help to determine
what changes need to be made for patient safety.
Outcomes
An article in the Online Journal of Issues in Nursing, gives support as to why a team
oriented fall prevention program should be implemented in a facility. In a study by Quigley et al.,
fall prevention programs put into place by utilizing data collected by nurses on patients helped to
decrease the number of falls hospital wide (2007). With the evaluation of data collected, an
appropriate goal in preventing falls from occurring in the medical setting will be determined.
Setting a goal to improve the management of falls would be the next step for the team. A practice
standard should be developed and put into place, while measuring outcomes will ensure the
practice standard is effective (Yoder-Wise, 2014). Such outcomes are used to develop a reliable
fall assessment risk tool that will help to evaluate patients and prevent falls from occurring.
Ensuring a safe environment may also be a valuable outcome: addressing spills, loose clothing,
and assistive walking tools for patients when ambulating. Increasing the education of the staff
will also be a key component.

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Implementation Strategies

In order to protect and provide safety for patients there needs to be policies and
procedures implemented. When there is a new policy implemented, it is crucial to have sufficient
employee education. The staff needs to be properly educated on the criterion that places patients
at an increased risk of falling. The staff should assess the patient every four hours on the
following criteria: previous fall, advanced age, medications they are taking, altered mental status
or impaired cognition, multiple diagnoses, mobility impairment or weakness, and if they use
assistive devices (William et al, 2014). If the patient meets the criteria as a high fall risk, it is the
interdisciplinary teams duty to make sure all the safety provisions are in place. The safety
requirements include: the bed in its lowest position with tab or bed alarm intact, complete
accurate signage at the door and/or in the chart, rounding every one to two hours to assess for
pain and toileting needs, properly educating on call light usage and having the proper colored
socks and yellow fall risk arm band in place (William et al, 2014). It is also the duty of anyone
who interacts with the patient to complete an environmental and individual assessment with
every interaction as a patients condition could change and adaptions should be continually made.
The only way to prevent a fall is by 100% compliance with newly implemented strategies.
Evaluation
To ensure that a policy is effective it needs to be properly evaluated. The quality
improvement (QI) process allows for a complete analysis and evaluation of the policy or change
to prevent potential errors and to provide patient safety and satisfaction. According to YoderWise (2014), The quality improvement process is a structured series of steps designed to plan,
implement, and evaluate changes in health care activities (p. 395). The data for the QI process
can be obtained by the statistics of falls that occurred before the implementation of the new

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policies and the statistics of falls after implementation of the fall policies. The patients can also
be surveyed to determine if they feel their needs are being met, which will decrease the number
of times they feel they have to get up independently. Similar to any new change, evaluations
need to be done to determine the additional changes needing to be made to provide the safest
environment possible for the patients.
Conclusion
A good fall prevention program is important for every institution to implement. By
forming an interdisciplinary team, creating a fishbone diagram to understand underlying cause
and effect, developing strategies to prevent falls, implementing these strategies, and evaluating
the effectiveness of these strategies, a fall prevention program should decrease the number of
falls within an institution. The quality improvement process should be utilized to help decrease
the number of falls within an institution.

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References

Colon-Emeric, C. S., McConnell, E., Pinheiro, S. O., Corazzini, K., Porter, K., Earp, K. M., &
Anderson, R. A. (2013). CONNECT for better fall prevention in nursing homes: Results
from a pilot intervention study. Journal of The American Geriatrics Society, 61(12),
2150-2159. doi:10.1111/jgs.12550
Quigley, P., Neily, J., Watson, M., Wright, M., & Strobel, K. (2007). Measuring Fall Program
Outcomes. Online Journal of Issues in Nursing. 2(12),DOI:
10.3912/OJIN.Vol12No02PPT01
The Joint Commission. (2008). Fall reduction program-NPSG-Goal 9. Retrieved from:
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqI
d=201&ProgramId=47
Williams, T., Szekendi, M., & Thomas, S. (2014). An analysis of patient falls and fall prevention
programs across academic medical centers. Journal of Nursing Care Quality 29 (1), 1929.
Yoder-Wise, P.S. (2014). Leading and managing in nursing (5th ed.). St. Louis, Mo: Elsevier
Mosby.