Safety Assessment Paper
Purpose:
Examine the safety factors of a selected client and reflect on nursing practice. The student will evaluate individual and healthcare environment risks to a client.
Process:
1. Write each section of the paper according to the following guidelines. Total length of paper 7-9 pages including title and reference pages and abstract.
2. Utilize current resources (literature, websites and text books)
3. Utilize APA for all guidelines for documentation and style.
4. Include a title page and the reference or bibliography page.
Refer to QSEN Guidelines which can be found at: http://qsen.org/competencies/pre-licensure-ksas/#safety
Joint Commission National Patient Safety Goals:
http://www.jointcommission.org/assets/1/6/2014_NCC_NPSG_E.pdf
Another source: the National Patient Safety Foundation
Make headings for each section. No errors in APA. Include abstract. Correct reference page. Use only credible nursing sources for research. – .com, wikepiedia is not accepted.
The paper will consist of the following sections:
A. Assessment of the culture of safety in the clinical agency.
1. Identify examples of nursing care related to safety.
2. Review agency policies and procedures.
3. Identify presence of safety cues in the environment.
4. Identify reporting mechanism for errors and their use in the clinical agency
B. Assessment of the client’s immediate environment for safety.
1. Identify sources of potential harm to the client: clutter, lighting, obstacles on the floor, timeliness of call light response, bed/chair alarms
2. Availability of safety equipment.
C. Assessment of home environment related to safety hazards.
1. Interview client and or family regarding home environment.
2. Identify sources of safety risk in the home.
3. Educate client about safety at home.
D. Assessment of the client’s physical, mental, and emotional status in terms of safety.
1. Complete clinical agency risk assessment tools (fall risk and skin assessment tool) and client’s health needs (glasses, hearing aids, and other physical conditions that may compromise safety)
E. Identify strategies used by the institution to meet national patient safety goals.
F. Identify and discuss on your role in error prevention for this client.
NUR 224 Adult/Geriatric Health-Chronic Care
EVALUATION OF SAFETY PAPER GRADING RUBRIC
Ideas and Concepts Expressed
25 pts ideas clearly and accurately included with a full and rich explanation all ideas and concepts of safety; writing commands attention
23 – 24 pts well-written; major ideas and concepts included; understandable and clearly expressed; information accurate
19 – 22 pts key ideas and concepts explained with a few areas of vagueness; writing lacks enthusiasm
15 – 18 pts explanation of key ideas and concepts generally lacks clarity; minimal key concepts and ideas identified
11 – 14 pts ideas and concepts minimally explained or not explained; minimal or no relationship to literature and or educational material
10 pts turned in the assignment
Comments:
Organization of Paper
15 pts well organized; logical flow of ideas and concepts, using transitions well; all components included
13-14 pts organized; logical flow of ideas; lacks transitional sentences; all components included
10-12 pts organized with a few areas of non-logical flow of ideas and concepts; all components included
6-9 pts organization fragmented; missing 1 component
1-5 pts lack of organization; multiple components missing
Comments:
Literature
5 pts minimum of 3 sources of literature related to nursing or safety
4 pts less than 3 sources of literature related to nursing or safety
3 pts 3 sources used but not all nursing sources (for example Wikepedia, dictionary, etc.)
2 pts 3 non-nursing sources used but related to topic
1 pts less than 3 non-nursing sources used and or not related to topic
Comments:
Critical Thinking
25 pts thoughts, ideas, and opinions regarding safety are clearly identified, thoroughly analyzed, and supported with literature
23 – 24 pts thoughts, ideas, and opinions regarding safety are identified, analyzed, and supported with literature
19 – 22 pts thoughts, ideas, and opinions regarding safety generally stated, with limited analysis, and weakly supported by literature
15 – 18 pts thoughts, ideas, and opinions regarding safety are vague and weakly supported by literature
10 – 14 pts minimal inclusion of thoughts, ideas; opinions not supported with literature
5 – 9 pts no inclusion of own thoughts or ideas; not supported with literature
Comments:
APA Documentation – Citation in Body of Paper (
5 pts no errors in APA documentation
4 pts 1 or 2 errors in APA documentation
3 pts consistently making same error or making 1 or 2 errors of different types
2 pts making multiple errors of different types
1 pts using APA inconsistently
Comments:
APA Formatting – Margins, Spacing, Page Number, Font, Font Size, Running Head
5 pts no errors in APA formatting
4 pts 1 or 2 errors in APA formatting
3 pts consistently making same error or making 1 or 2 errors of different types
2 pts making multiple errors of different types
1 pts using APA formatting inconsistently
Comments:
Bibliography/Reference Page/Appendix Correct APA Format
5 pts no errors in APA format
4 pts 1 or 2 errors in APA format
3 pts consistently making same error or 1 or 2 errors of different types
2 pts consistently making multiple errors
1 pts using APA format inconsistently
Comments:
Grammar, Spelling, Sentence Structure
10 pts no errors
8 – 9 pts 1 or 2 errors in grammar, spelling, or sentence structure
5 – 7 pts consistently making same error or 1 or 2 errors of different types in grammar, spelling, or sentence structure
1 – 4 pts consistently making multiple errors of different types in grammar, spelling, or sentence structure
Comments:
Title Page
5 pts no errors in format, all information included
4 pts 1 error
3 pts 2 errors
2 pts 3 or more errors
1 pts required information not included, did not follow format
Comments:
About patient:
The approach in this paper: due to client immobility that puts him at risk for many safety issues:
– Risk for fall due to immobility – weak muscle, dementia
– Risk for pleasures ulcer due to immobility- already several pressure ulcers and many skin breakdowns that can easy be infected.
– Risk for pneumonia due to immobility
– Client wearing pressure relief boots which put client risk of fall if he try stand up.
– Problem with circulation
– Etc.
Client is 87 years old male with progressive dementia. He is only oriented to name and birthday. He was admitted to Cedar Springs Health Rehab Center with infected unstageable wound on his heel. He had MRSA. Sepsis.
Also he had ulcer on his left big toe with osteomyelitis. Keratosis on his scalp.
Was getting vancomycin until he ripped off his line 3 times. They give him different antibiotic PO.
After week patient is doing better with his infection.
• They found out that he also had UTI
• Malnutrition- client under nutrition risk for falls, problems with wounds healing.
• Several breakdowns of skin on his arms.
• Very hard of hearing bilateral
• Problem with swallowing- diet specifications- mech. Soft, liquid thicken, must have supervision with eating
• History of aspiration pneumonia
• Client denies reposition due to pain in his leg
• Bowel and bladder incontinent
• Immobile, need assistant
Safety issues in the clinical agency:
• Most the time short of staff- not responding to patients in timely matter, risk for client’s safety in verity situations. Not responding to call aid. Lady put on her call light and I watched not one person came to help her. Finally, after 2 hours someone came.
• contact precaution for MRSA (infected pressure ulcer) without personal protective equipment PPE. Nurse told me that there is no need to put gown on, only when wound is uncovered I should use this precaution. This huge risk for me and other residents for spreading the infection.
• Nurse changed pressure ulcer dressing without gloves, then she puts lotion starting from feet to moves arms and lastly to the hands. Big risk for many problems for nurse, client and other residents.
• Poor hygiene for residents
Cedar Springs Health & Rehabilitation Center: SOME Agency policies and procedures (guidelines):
Contact precaution MRSA
These standard precautions should control the spread of MRSA in most instances.
DC recommends contact precautions when the facility (based on national or local regulations) deems MRSA to be of special clinical and epidemiologic significance. The components of contact precautions may be adapted for use in non-hospital healthcare facilities, especially if the patient has draining wounds or difficulty controlling body fluids.
These contact precautions should be followed for some patients. To determine if a patient needs to be placed on Contact Precautions see page 38 of Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006 [PDF 233 KB]
1. Patient placement
In Patient placement in hospitals and LTCFs, when single-patient rooms are available, assign priority for these rooms to patients with known or suspected MRSA colonization or infection. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions. When single-patient rooms are not available, cohort patients with the same MRSA in the same room or patient-care area. When cohorting patients with the same MRSA is not possible, place MRSA patients in rooms with patients who are at low risk for acquisition of MRSA and associated adverse outcomes from infection and are likely to have short lengths of stay.
In general, in all types of healthcare facilities it is best to place patients requiring Contact Precautions in a single patient room. To assist with decision making about patient placement in various types of healthcare facilities see page 84 of Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 PDF (3.80 MB / 225 pages).
2. Gloving
Wear gloves whenever touching the patient’s intact skin or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into the room or cubicle.
3. Gowning
Don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving the patient-care environment. After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces.
4. Patient transport
In acute care hospitals and long-term care and other residential settings, limit transport and movement of patients outside of the room to medically-necessary purposes. When transport or movement in any healthcare setting is necessary, ensure that infected or colonized areas of the patient’s body are contained and covered. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions. Don clean PPE to handle the patient at the transport destination.
5. Patient-care equipment and instuments/devices
In acute care hospitals and long-term care and other residential settings, use disposable noncritical patient-care equipment (e.g., blood pressure cuffs) or implement patient-dedicated use of such equipment. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient.
In home care settings limit the amount of non-disposable patient-care equipment brought into the home of patients on Contact Precautions. Whenever possible, leave patient-care equipment in the home until discharge from home care services. If noncritical patient-care equipment (e.g., stethoscope) cannot remain in the home, clean and disinfect items before taking them from the home using a low- to intermediate-level disinfectant. Alternatively, place contaminated reusable items in a plastic bag for transport.
6. Environmental measures
Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and disinfection (e.g., at least daily) with a focus on frequently-touched surfaces (e.g., bed rails, overbed table, bedside commode, lavatory surfaces in patient bathrooms, doorknobs) and equipment in the immediate vicinity of the patient.
Pressure ulcer policies and procedures.:
Pressure ulcers are a serious problem that affects approximately 9 percent of all hospitalized patients and 23 percent of all nursing home patients. This condition can be difficult to treat and often results in pain, disfigurement, and prolonged hospitalization. However, prompt and effective treatment can minimize these deleterious effects and speed recovery.
A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually located over bony prominences and are graded or staged to classify the degree of tissue damage observed; however, pressure ulcers do not necessarily progress from Stage I to Stage IV or heal from Stage IV to Stage I. The staging of pressure ulcers recommended for use here is consistent with the recommendations of the National Pressure Ulcer Advisory Panel Consensus Development Conference:
Stage I: Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.
Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.
These staging definitions recognize the following limitations:
• Stage I ulcers may be superficial, or they may be a sign of deeper tissue damage.
• Stage I pressure ulcers are not always reliably assessed, especially in patients with darkly pigmented skin.
• When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed.
• It may be difficult to assess pressure ulcers in patients with casts, other orthopedic devices, or support stockings. Extra vigilance is required to assess ulcers under these circumstances.
This guide provides a comprehensive program for treating individuals with Stage II, III, and IV pressure ulcers. The recommendations are intended for clinicians who examine and treat persons who have pressure ulcers. These recommendations will be of interest to family physicians, internists, geriatricians, physiatrists, nurses and nurse practitioners, enterostomal therapists, infection control officers, physical and occupational therapists, psychological support staff, and dietitians in acute care, long-term care, rehabilitative, geriatric, and home settings. Although these recommendations are based on research involving adults, they may, at the clinician’s discretion, be applied to children (but not to neonates).
Highlights of Patient Management
Effective pressure ulcer treatment is best achieved through a team approach involving patients, their families or caregivers, and health care providers. The clinician should:
• Discuss pressure ulcer treatment options with patients and their families.
• Encourage patients to be active participants in their care.
• Develop an effective plan of care that is consistent with the patient’s goals and wishes.
The recommended treatment program should focus on:
• Assessment of the patient and the pressure ulcer(s).
• Managing tissue loads.
• Ulcer care.
• Managing bacterial colonization and infection.
• Operative repair of the pressure ulcer(s).
• Education and quality improvement.
• Assessment
• Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer. Assessment involves the entire person, not just the ulcer, and is the basis for planning treatment and evaluating its effects. Adequate assessment is also essential for communication among caregivers. This section discusses recommendations for assessing the pressure ulcer and the individual.
Reassessment. Reassess pressure ulcers at least weekly (as shown in Figure 2). If the condition of the patient or wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted.
Monitoring progress. A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary.
Assessing the Individual
Assessment of the individual should address physical health, complications, nutritional assessment and management, pain assessment and management, and psychosocial assessment and management.
Physical Health and Complications
History and physical examination. Perform a complete history and physical examination, because a pressure ulcer should be assessed in the context of the patient’s overall physical and psychosocial health.
Complications. Clinicians should be alert to the potential complications associated with pressure ulcers, such as amyloidosis, endocarditis, heterotopic bone formation, maggot infestation, meningitis, perineal-urethral fistula, pseudoaneurysm, septic arthritis, sinus tract or abscess, squamous cell carcinoma in the ulcer, and systemic complications of topical treatment (e.g., iodine toxicity and hearing loss after topical neomycin and systemic gentamicin). Three other complications–osteomyelitis, bacteremia, and advancing cellulitis–are discussed later in the recommendations for managing bacterial colonization and infection.
Nutritional support. Encourage dietary intake or supplementation if an individual with a pressure ulcer is malnourished. If dietary intake continues to be inadequate, impractical, or impossible, nutritional support (usually tube feeding) should be used to place the patient into positive nitrogen balance (approximately 30 to 35 calories/kg/day and 1.25 to 1.50 grams of protein/kg/day) according to the goals of care. As much as 2.00 grams of protein/kg/day may be needed.
Vitamin and mineral supplements. Give vitamin and mineral supplements if deficiencies are confirmed or suspected.
While in Bed
Positioning techniques and support surfaces for patients in bed are important factors in the management of tissue loads.
Positioning Techniques
Staying off the ulcer. Avoid positioning patients on a pressure ulcer.
Positioning devices. Use positioning devices to raise a pressure ulcer off the support surface. If the patient is no longer at risk for developing pressure ulcers, these devices may reduce the need for pressure-reducing overlays, mattresses, and beds. Avoid using donut-type devices, which are more likely to cause pressure ulcers than to prevent them.
Written schedules. Establish a written repositioning schedule based on the patient’s risk for additional ulcers and on the response of the tissue to pressure. Patients at higher risk of additional ulcers and those with a longer duration of reactive hyperemia should be turned more frequently. Written repositioning schedules should be developed even when patients are using pressure-reducing support surfaces, because these surfaces are only adjuncts to strategies for positioning and careful monitoring of at-risk patients.
Indications for static support surfaces. Use a static support surface if a patient can assume a variety of positions without bearing weight on a pressure ulcer and without “bottoming out.” The caregiver can determine whether the patient has bottomed out by placing an outstretched hand (palm up) under the overlay below the pressure ulcer or below the part of the body at risk for a pressure ulcer. If the caregiver feels less than an inch of support material, the patient has bottomed out and the support surface is inadequate.
Indications for dynamic support surfaces. Use a dynamic support surface if the patient cannot assume a variety of positions without bearing weight on a pressure ulcer, if the patient fully compresses the static support surface, or if the pressure ulcer does not show evidence of healing.
Indications for low-air-loss and air-fluidized beds. If a patient has large Stage III or Stage IV pressure ulcers on multiple turning surfaces, a low-air-loss bed or an air-fluidized bed may be indicated. A low-air-loss bed may also be indicated if the individual bottoms out or fails to heal on a dynamic overlay or mattress.
Need to control moisture. When excess moisture on intact skin is a potential source of maceration and skin breakdown, a support surface that provides airflow (e.g., air-fluidized and low-air-loss beds) can be important in drying the skin and preventing additional pressure ulcers. While lying on this type of support surface, patients should not wear incontinence briefs because the briefs obstruct airflow to the skin. Follow manufacturers’ instructions for using linen and underpads.
Debridement
Moist, devitalized tissue supports the growth of pathological organisms. Therefore, the removal of such tissue favorably alters the healing environment of a wound. Although debridement is a time- honored modality for treating pressure ulcers, it has not been studied in a randomized trial.
Removal of devitalized tissue. Remove devitalized tissue in pressure ulcers when appropriate for the patient’s condition and consistent with patient goals.
Selection of a method. Select the method of debridement most appropriate to the patient’s condition and goals.
• Sharp, mechanical, enzymatic, and/or autolytic debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalized tissue.
• Sharp debridement involves the use of a scalpel, scissor, or other sharp instrument to remove devitalized tissue. This method is the most rapid form of debridement and may be the most appropriate technique for removing areas of thick, adherent eschar and devitalized tissue in extensive ulcers.
• If there is an urgent need for debridement, as with advancing cellulitis or sepsis, sharp debridement should be used.
• Those performing sharp debridement should have demonstrated the necessary clinical skills and meet licensing requirements.
• Although small wounds can be debrided at the bedside, extensive wounds are usually debrided in the operating room or in a special procedures room. When debriding extensive Stage IV ulcers in the operating room, the surgeon should consider a bone biopsy to detect osteomyelitis.
• Mechanical debridement techniques include wet-to-dry dressings, hydrotherapy, wound irrigation, and dextranomers.
• Enzymatic debridement is accomplished by applying topical debridement agents to devitalized tissue on the wound surface.
• Autolytic debridement involves the use of synthetic dressings to cover a wound and allow devitalized tissue to self-digest from enzymes normally present in wound fluids. This technique should not be used if the wound is infected.
Dressings during and after debridement. Use clean, dry dressings for 8 to 24 hours after sharp debridement associated with bleeding; then reinstitute moist dressings. Clean dressings may also be used in conjunction with mechanical or enzymatic debridement techniques.
Stable heel ulcers, an exception. Heel ulcers with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement (e.g., edema, erythema, fluctuance, drainage).
Pain. Prevent or manage pain associated with debridement as needed.
Wound Cleansing
Wound healing is optimized and the potential for infection is decreased when all necrotic tissue, exudate, and metabolic wastes are removed from the wound. The process of cleansing a wound involves selecting both a wound-cleansing solution and a mechanical means of delivering that solution to the wound. The benefits of obtaining a clean wound must be weighed against the potential trauma to the wound bed as a result of such cleansing. Routine wound cleansing should be accomplished with a minimum of chemical and mechanical trauma.
Cleansing. Cleanse wounds initially and at each dressing change.
Nontraumatic technique. Use minimal mechanical force and less coarse materials when cleansing the ulcer with gauze, cloth, or sponges.
Avoidance of antiseptics. Do not clean ulcer wounds with skin cleansers or antiseptic agents (e.g., povidone iodine, iodophor, sodium hypochlorite solution [Dakin’s solution], hydrogen peroxide, acetic acid), because they are cytotoxic. Table 2 delineates a toxicity index by listing the dilutions required for various skin and wound cleansers to maintain the viability and phagocytic function of white blood cells exposed to these agents.
Fall:
Evaluation/Risk Assessment
1. Evaluation of history of falls
2. Assessment of risk of falls and post-fall evaluation (fall history, medications, underlying conditions, functional status, neurological status, psychological factors, environmental factors)
3. Identification of nature, frequency, and causes of individual’s falls
4. Identification of actual and potential complications of falls
Management/Prevention
1. Development of a plan for managing falls and fall risks
2. Management of the causes of falling (e.g., implementing restorative or rehabilitative care to improve strength, balance, gait, and transferring ability; educating regarding managing orthostatic hypotension; evaluating and managing medication use)
3. Implementation of relevant general measures to address falling and fall risks (e.g., facility approaches, exercise and balance training, use of physical restraints, use of alarms, environmental modifications)
4. Monitoring of falling in individuals with fall risk or fall history
5. Conducting quality improvement activities related to falls
Major Outcomes Considered
• Risk, frequency, and incidence of falls and fall-related injuries
• Morbidity and mortality related to falls
• Other measures, such as patient and family satisfaction, use of physical restraints, and quality of lif
Recognition
Step 1
Does the patient have a history of falls?
A history of falls is a strong predictor of future falls. Review the patient’s record for evidence of previous falls. Ask the patient and the patient’s caregiver or family if the patient has a history of falling. A history of one or more recent falls, for any reason, within 6 months should be listed as a problem in the patient’s record. The potential for further falling should be addressed in the patient’s care plan, either separately or in conjunction with care plans related to other risk factors associated with increased fall risk.
Step 2
Is the patient at risk of falling?
Many risk factors are associated with falls (see Table 1 in the original guideline document). Multiple factors are often involved in a given patient. Some classes of medications impair alertness and balance or cause orthostatic hypotension (see Table 2 in the original guideline document).
Document risk factors for falling in the patient’s record and discuss the patient’s fall risk in care conferences. Table 3 in the original guideline document lists items that may need to be reviewed when assessing a patient’s fall risk, including the following risk categories:
• Fall history
• Medications
• Underlying conditions
• Functional status
• Neurological status
• Psychological factors
• Environmental factors
Assessment
Step 3
Has the patient just fallen?
Provide staff with a clear, written procedure that describes what to do when a patient falls. When a patient has just fallen or is found on the floor without a witness to the fall, a nurse should record vital signs and evaluate the patient for possible injuries to the head, neck, spine, and extremities. If there is evidence of a significant injury, such as a fracture or bleeding, provide appropriate first aid, notify the practitioner and family, and get emergency assistance if necessary.
Transfer of the patient to a hospital emergency room is appropriate if he or she exhibits the following injuries or signs after a fall:
• Uncontrolled bleeding
• Major fracture or fracture likely to require surgical intervention
• Deformity of limbs
• Acute change in neurological status or cognition (see Table 4 in the original guideline document)
Step 4
Evaluate the factors associated with the fall.
It is insufficient to say simply that a patient has a “fall risk” or a “problem with falling.” After an observed or probable fall, or after a fall risk has been identified, a more detailed analysis of the patient’s falling or fall risk should take place.
Identifying the Causes of a Fall
Identifying and correcting the causes of falls can often reduce the risk of falling. For patients who have recurrent falls, continue to collect and evaluate information until either (1) the cause of the falling is identified or (2) it is determined that the cause cannot be found or that finding a cause would not change the outcome or the patient’s management. If possible, document how it was concluded that certain factors contributed to or caused falling whereas others were not relevant. No further evaluation may be necessary if the fall is clearly the result of an obvious extrinsic factor that can be corrected.
Performing a Post-Fall Evaluation
After a fall, obtain relevant history regarding the circumstances (see Table 5 in the original guideline document). The patient’s current medications, especially any recent changes, should also be reviewed. A postural blood pressure and pulse should be obtained along with a gait and balance evaluation. (Box 1 in the original guideline describes the steps for assessing for orthostatic hypotension.)
Step 5
Identify the patient’s actual and potential complications of falls.
Some falls may result in significant complications (see Table 7 in the original guideline document). It is important to define complications of falls and significant potential complications of falling for each patient. For example, different types of falls carry different risks of injury. Direction of falling affects risk—there is an increased risk of fracture if the resident falls sideways. Energy and speed of the fall also increase the risk of injury. Posterolateral falls carry the highest risk of hip injury.
Treatment
Step 6
Develop a plan for managing falls and fall risks.
Care goals should include prevention of falls when possible, a decrease in the number of falls, and a decrease in the risk and severity of injury. It is unrealistic to expect to eliminate all falls, but an appropriate goal for many patients may be to reduce the number of falls and the risk of injury. The management of falls and fall risk may involve one or several measures.
Step 7
Manage the cause(s) of falling.
Managing falls can be complicated because many falls result not from a single cause but from the interaction of several factors. Successful fall management uses a systematic approach that may require repeated reassessment and adjustment.
Cause-specific interventions are only sometimes available and effective. At other times, the best that can be done is to try various interventions until falling is reduced or stops or until an uncorrectable reason is identified for its continuation.
Refer to the original guideline document for suggested interventions for:
• Falls caused by disturbances of gait or balance
• Falls caused by orthostatic hypotension
• Falls associated with medications
• Falls associated with specific conditions (vitamin D deficiency, anemia, urinary incontinence, diabetes)
Step 8
Implement relevant general measures to address falling and fall risks.
Various generic approaches (i.e., those that are not directed at specific causes) can have an impact on the prevention and management of falls (see table below). Coordinate clinical initiatives to prevent and manage falls with initiatives of the interdisciplinary team (IDT) and facility safety committee, reviews of falls by the quality improvement committee, and efforts to ensure a safe environment for wanderers.
Table. Examples of Facility Approaches to Try to Reduce Falls or Consequences of Falls
• Activities program
• Function-focused care philosophies (e.g., restorative care, exercise programs)
• Patient education about safe sitting and standing
• Program to help patients and families cope with and adapt to nonmodifiable risk factors for falling
• Programs for patients who wander
• Reduction in the use of physical restraints
• Rehabilitation program (e.g., balance training, strengthening, gait training, assistive devices)
• Staff education about fall risks and potentially helpful interventions
• Toileting and continence programs or a timed voiding schedule
• Hip protectors
Monitoring
Step 9
Monitor falling in patients with a fall risk or fall history.
Monitor and document the patient’s response to interventions intended to reduce falling or the risk of falling. It may be helpful for the pharmacy consultant to conduct a medication review after a fall to evaluate and rule out any medication risk factors. If interventions have been successful in preventing falling, continue with current approaches or reconsider whether those measures are still needed if the problem that required the intervention (e.g., dizziness, joint pain) has resolved or been corrected.
If the patient continues to fall, re-evaluate the situation and reconsider current interventions. Amend the care plan as necessary to reflect the addition of new interventions and the need for continued monitoring. Document the presence of irreversible risk factors. Also, consider relevant interventions to try to minimize fall-related injuries (e.g., using hip protectors, treating osteoporosis).
If falls continue despite initial interventions, the reason could be that different or additional causes exist, the underlying causes are not readily correctable, the cause cannot be identified, or the interventions are insufficient. Consider other possible reasons for the patient’s falling besides those that have already been identified, or document why a further search for causes is unlikely to be helpful.
Step 10
Establish quality improvement activities related to fall risk and falling.
Include analysis of falls in the facility’s quality improvement studies. Track accidents and falls by (at a minimum) time, location, and identified categories of causes. The total number of falls will fluctuate from month to month.
Evaluate the process associated with fall prevention or interventions that are implemented; interventions need to be implemented as intended in order for them to be optimally effective. Indicators that fall prevention processes and interventions are being implemented might include evidence that post-fall assessment of patients is completed and identified causes have been addressed (e.g., removal or replacement of unsafe assistive devices, discontinuation of medications that cause orthostatic hypotension) and that patients are participating in a muscle-strengthening exercise class. Relate these data to care processes to ensure that everything reasonable is being done to identify risk factors for falling and take appropriate preventive measures (see “Performance Measures” in the original guideline document). Table 10 in the original guideline document lists additional sample performance measurement indicators.
The medical director can play a pivotal role in fall prevention and management, including:
• Setting the expectation of all facility staff that fall risk assessment and fall prevention are facility priorities as they relate to both patient safety and facility liability
• Helping to develop and use appropriate policies and procedures on falls and fall risk
• Providing education and information about potential medical causes of falling
• Ensuring appropriate and timely practitioner assessment and intervention when medications or medical conditions may be causing or contributing to falls when falls occur
Refer to QSEN Guidelines which can be found at: http://qsen.org/competencies/pre-licensure-ksas/#safety
Joint Commission National Patient Safety Goals:
http://www.jointcommission.org/assets/1/6/2014_NCC_NPSG_E.pdf
Another source: the National Patient Safety Foundation
https://issuu.com/hospitalemfoco/docs/handbook_patient_safety
add other sources
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