Memo – Patient Fall Incident and Risk Mitigation Strategies

Memo – Patient Fall Incident and Risk Mitigation Strategies

TO: Risk Management Team and Staff

FROM: [Your Name], Risk Manager

DATE: June 20, 2024

RE: Patient Fall Incident and Risk Mitigation Strategies

Facts

On an unspecified date, a patient was admitted to the medical floor of our healthcare facility. Upon admission, the patient exhibited signs of confusion. Despite this, the patient was placed in a room at the end of the hall, far from the nurses’ station, where direct observation was limited. The patient repeatedly attempted to leave her bed without using the call light provided. Staff members were not able to consistently monitor the patient due to her room location. Eventually, the patient fell, resulting in an injury.

This occurrence makes me worry about the security of the patients, the work procedures of staff, and the layout of the institution. The point of reference for admitting a patient who was already showing signs of confusion was missed, and hence, no proper precaution was observed. Given the patient’s condition, inadequate monitoring seems to have been done, thus suggesting that there were gaps in provision.

Issue Presented

Are our current practices on patient placements, risk assessment mechanisms for at-risk patients, and fall prevention strategies sufficient enough to ensure safety and minimize falls among confused as well as disoriented patients?

Brief Answer

No, present practices for patient placement, monitoring at-risk-patients care, and fall prevention strategies cannot ensure that safety is achieved in terms of fall prevention. This episode reveals significant holes in our risk management approach especially concerning people with confusion or disorientation. It, therefore, calls for immediate action to address these gaps by implementing stronger measures aimed at preventing falls.

Analysis

1. Risk Management and Issue Identification

The major risk management issue presented here is inadequate fall prevention approaches, mainly concerning confused or disoriented patients. In this case, several lessons come up from this incident where some require improvement:

1. Inappropriate room assignment: For safety reasons, a disoriented patient should not be placed in a room further from the nurses’ station, where they run the risk of falling and no one seeing them.
2. Insufficient monitoring: The patient was trying to get out of the bed without pulling the call light several times, meaning that the patient was not under appropriate observation.
3. Failure to implement preventive measures: In this case, fall precautions that need to be implemented have not been applied despite the patient’s confusion already known or documented.
4. Potential staffing issues: Nursing care cannot be delivered consistently if patient care is being supervised intermittently, which raises questions about staffing shortages or poor staffing distribution.

All these factors combined caused a preventable fall, thus causing harm to the patient and potential legal liability to the facility.

Recommended Resolution

2. Risk assessment protocol: Creation and introduction of templates of assessment tools for recognizing patients’ fall risk possibility during their admission and periodically during their stay.
3. Room assignment policy: Developing a policy that allocates patient rooms based on certain standards with an especially keen focus on monitoring high-risk individuals.
4. Enhanced monitoring systems: Usage of technologies like the use of alarm systems and video monitoring to serve high-risk patients.
5. Staff training: Making sure a detailed orientation on the appropriate measures to implement for fall protection with an emphasis on proper handling of the patients who are confused is conducted to the staff.
6. Environmental modifications: Establishment of a fall risk checklist on the premises to eliminate fall risks, including lack of adequate lighting and poorly constructed handrails.
7. Patient and family education: Design information and resources for the patient, Fernando, and his family to participate in the fall prevention process.
8. g) Post-fall analysis protocol: Implement a standard approach for handling falls when they occur so that ongoing improvements to preventative measures can be implemented.

Key Decision-Making Points

The decision-making process leading to these recommendations was guided by several key considerations:

1. Patient safety as the primary concern: All recommendations prioritize patient safety, striving to create a safer environment.
2. Evidence-based practices: The recommended strategies are based on established best practices in fall prevention outlined in current medical literature as well as Joint Commission guidelines (Cameron et al., 2018).
3. Systemic approach: Rather than focusing solely on the specific incident, the recommendations address system-wide issues to prevent similar occurrences across the facility.
4. Cost-effective measures: Although some recommendations may call for a certain level of initial investment, they are expected to result in long-term savings through the reduction of fall-related injuries and litigations that may arise from them.
5. Adhering to regulations: The adopted measures conform with the regulatory requirements and the accreditation standards that concern patient safety as well as risk management.

Risk Management Tools

To analyze, solve, and monitor this issue, I would deploy the following risk management tools:

1. Root Cause Analysis (RCA): This tool would be used to comprehensively investigate the falling incidence by identifying all factors causing it as well as probable points that need intervention. RCA would normally comprise different professionals analyzing event timelines and interviewing people involved therein alongside examining relevant guidelines (Peerally et al., 2017).
2. Failure Mode and Effects Analysis (FMEA): This preventive tool will be used to evaluate our fall prevention processes systematically so that potential weak points can be detected before the occurrence of adverse events. FMEA would involve sketching out each stage of our patient’s care –from admission to discharge- to do a check on where falls might happen (DeRosier et al., 2002).

These tools would help in gaining a comprehensive understanding of the risks involved and develop targeted interventions to address them.

Collaboration with Quality Manager

To deal with this matter effectively, we will have to work closely with the Quality Manager. Our joint efforts would focus on:

1. Data collection and analysis: Collaboratively create ways to evaluate fall rates and the efficiency of mitigating interventions.
2. Policy development: Participate in developing or updating policies concerning falls in the unit to strive towards risk management goals and/or quality improvements.
3. Staff education: Craft and apply training procedures in terms of risk management concepts and total quality improvement approaches.
4. Continuous improvement: Develop a system that will help us feed the data collected from incidents back into the system to help shape the ongoing improvement process of fall prevention strategies.
5. Accreditation preparation: Guarantee that the measures we are taking towards the prevention of fall incidents correspond to the guidelines of the accreditation standard and bring materials providing evidence of our improvement activities to this end.

With this kind of cooperation, the mitigation of risks will be aligned with overall activities for the improvement of the quality of care, making the program for patient safety more efficient.

Anticipated Challenges

6. Resource constraints: Funding constraints affect the integration of change processes such as new technologies and enhanced staffing levels.
7. Resistance to change: Sometimes, employees’ resistance could come up due to changes in procedures or even technologies required to be used; there is therefore need to employ effective change management strategies.
8. Balancing patient autonomy and safety: Patients’ rights and patients’ dignity might become a concern due to the enhanced focus and limitations on mobility among patients.
9. Complexity of fall prevention: Because multiple factors cause falls, it might be cumbersome to manage such factors appropriately.
10. Sustaining improvements: It may also prove challenging to sustain changes in care delivered to patients over a long time hence the need to focus on the issue of falling.
11. Legal and ethical considerations: Improving this type of monitoring might bring questions about personal data privileges that must be addressed.

These are issues that are yet to be addressed through constant dialogues, information sharing, and evaluation of the strategies employed as the implementation proceeds.

Conclusion

The patient fall incident has revealed significant gaps in our current fall prevention practices. With the consideration of carrying out a multi-faceted approach on the topic of fall prevention, the availability and use of risk management tools, team cooperation with the Quality Manager, and the consideration of potential challenges, the level of patient safety can be enhanced, and the occurrence of falls minimized. By adopting this approach, patients’ status will be improved, and likely legal and financial challenges for the facility will be addressed as well. These strategies need to be monitored and changed often in the future as well for them to remain effective.

References

Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, (9), CD005465. https://doi.org/10.1002/14651858.CD005465.pub4

DeRosier, J., Stalhandske, E., Bagian, J. P., & Nudell, T. (2002). Using health care Failure Mode and Effect Analysis™: the VA National Center for Patient Safety’s prospective risk analysis system. The Joint Commission Journal on Quality Improvement, 28(5), 248-267. https://doi.org/10.1016/S1070-3241(02)28025-6

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2017). The problem with root cause analysis. BMJ Quality & Safety, 26(5), 417-422. http://dx.doi.org/10.1136/bmjqs-2016-005511

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As a risk manager, you will constantly analyze risk-management decision-making in health care. One of your responsibilities is to provide updates at monthly staff meetings to inform all staff of the current risks and how the risk management team is working to mitigate those risks and the risk management tools you have used.

Preparation
Read the following scenarios and choose 1 to focus on for this assignment.

Scenario 1

A patient arrives at the emergency department and is admitted for increased pain with the source unknown. The on-call physician asks the intake staff, “What is the source of payment for the patient?” in order to assist with his decision to treat the patient. The physician then declines to see the patient based on the patient’s lack of health insurance.

Scenario 2

A patient is admitted to the medical floor in a healthcare facility. She is confused and won’t stay in her bed. The patient is placed in a room at the end of the hall away from the nurses’ station and she is not easily seen by staff. The patient continues to get out of bed without using her call light and eventually falls, resulting in an injury.

Assessment Deliverable
Write a 700- to 1,050-word memo to be shared at the next monthly staff meeting addressing the following prompts for your chosen scenario. Be clear and concise, use complete sentences, and use your own words. Follow standard grammar rules and provide examples where appropriate to support your answers.

Identify the risk management issue presented in your chosen scenario.
Recommend how you would resolve the issue.
Identify key points in your decision-making process that led you to your resolution.
Explain how you would use at least 2 risk management tools to analyze, solve, or monitor the issue.
Explain how you would work with the quality manager to address the issue.
Describe challenges you foresee with the proposed resolutions.

Cite your sources according to APA guidelines.