Risk Factors Report – Patient falls

Risk Factors Report – Patient falls

Description of the Chosen Risk and an Example Scenario

Patient falls are one of the major health risks in healthcare contexts, with their potentially severe consequences for patients and providers. Patient falls are events whereby an individual receiving medical attention unintentionally comes to the floor, ground, or a lower level. The effects of falls may cause minor bruises or serious trauma; more often than not, they involve additional days of hospitalization, which increases healthcare expenses and losses, thus contributing to poor quality of life in patients.

To illustrate this risk, consider the case of Mrs. Johnson, an elderly patient who was admitted for treatment of her pneumonia. On the third night in the hospital, confused and not heeding any requests to push her call light for help, she attempts to use the bathroom on her own. Mrs. Johnson falls following a loss of balance and sustains a fracture of her hip. The incident shall prepare her for surgery, extend her stay in the hospital, and produce middleware consequences on her recovery and, ultimately, on her ability to enjoy good long-term mobility.

Risk Factors Affecting Patient Falls

Many factors, both internal and external to the healthcare organization, contribute to the risk of patient falls. These include internal factors such as patient characteristics—age, cognitive impairment, and mobility problems—plus environmental hazards like slippery floors and lack of sufficient lighting (Najafpour et al., 2019). Other critical contributors are staffing levels, lapses in communication at shift changes, and insufficiency of staff education regarding fall prevention strategies.

Extrinsic factors include regulatory pressures, public perceptions of patient safety, the legal environment for fall-related injuries, and technological change in preventing falls (Najafpour et al., 2019). Demographic trends in an aging population further increase the overall risk of falls in healthcare settings.

Role of Accreditation Standards and Regulations

Accreditation standards and regulations play a huge role in addressing patient fall risks. This includes certain patient safety goals that organizations such as The Joint Commission have developed concerning the prevention of falls, whereby certain falls are viewed by the Centers for Medicare & Medicaid Services (CMS) as “never events,” affecting reimbursement (The Joint Commission, 2021). These also influence best practices throughout the industry, for instance, through evidence-based guidelines and toolkits sponsored by the Agency for Healthcare Research and Quality regarding fall prevention (Frank et al., 2020).

These standards and regulations establish minimum requirements for fall prevention programs, promote standardization of risk assessment tools and interventions, encourage continuous quality improvement, and create accountability for patient safety outcomes. Many states also have legislated laws that require the assessment of fall risk and prevention programs in healthcare facilities, thus putting more emphasis on this issue.

Challenges to Addressing Patient Falls

Among the several challenges of addressing patient fall risks to healthcare organizations, resource allocation for a comprehensive fall prevention program at a time when budgets are extremely thin is highlighted by van Wijck et al. (2019). The staff remains consistently engaged and adheres to the fall prevention protocols in all shifts and departments, which becomes strenuous in stressful environments. Another challenge is that patients often do not comply well with fall prevention measures since they may sometimes resist what they perceive as restrictions to independence. However, balancing mobility and safety raises a challenging tradeoff since very restrictive measures can induce functional decline in patients.

Moreover, data collection, analysis, and interpretation of fall incidents and near-misses are complex and resource-consuming processes. This is a time-consuming and time-intensive process to determine trends and areas for improvement (van Wijck et al., 2019). Individualized fall prevention planning for patients with highly variable needs is also time-consuming and requires considerable expertise. Integration of new fall prevention technologies is sometimes troublesome due to staff tension and workflow disruption.

Risk Manager Adaptations to Overcome Challenges

To effectively address these challenges and mitigate future risks, risk managers must adapt their strategies. Fostering interdisciplinary teams involving nursing, physical therapy, pharmacy, and environmental services can lead to more comprehensive fall prevention programs (Iorio, 2024). Implementing robust incident reporting systems and utilizing analytics enables data-driven decision-making to target high-risk areas or populations.

Developing ongoing training programs for staff at all levels emphasizes the importance of fall prevention and disseminates best practices. Accordingly, creating educational materials and involving patients and their families in fall prevention efforts can improve compliance and outcomes. Promoting a non-punitive reporting environment encourages staff to report near-misses and potential hazards without fear of reprisal.

Moreover, risk managers should stay current with the latest research and guidelines on fall prevention, regularly updating organizational protocols (Iorio, 2024). Careful evaluation of new fall prevention technologies, considering both efficacy and ease of integration into existing workflows, is essential. Aligning staff performance metrics and incentives with fall prevention goals can encourage consistent adherence to protocols.

Future Trends Affecting Patient Fall Risk Management

Several emerging trends will likely impact patient fall risk management in the coming years. Artificial intelligence and predictive analytics may improve fall risk assessment accuracy and enable more targeted interventions (Turner et al., 2020). Wearable technology could provide real-time monitoring of patient movement and alert staff to potential fall risks. In addition, virtual reality training can also enhance staff education in the areas of fall prevention techniques and patient handling. Advancements in telemedicine could make this even possible in home care settings for the risk assessment of falls and intervention. For personalized medicine, as genetic and pharmacogenomic insights are leaned on, approaches to fall prevention might become tailored to the profile of each patient.

Workforce changes, including an aging nursing population and possible staffing shortages, may be other drivers for new approaches to fall prevention. Value-based care models emphasize better outcomes for patients at lower costs and can stimulate further innovation in strategies to prevent falls(Turner et al., 2020). Evidence-based architectural and interior design principles could make up a large part of healthcare facilities in the near future to reduce fall risks.

In other words, patient falls remain one of the most important risks healthcare faces today, and risk managers will have to deal with the issue and adjust accordingly. Understanding the multidimensional nature of this risk, working with accreditation standards, creative problem-solving, and preparing for the future can help a healthcare organization sharply reduce fall incidents and simultaneously improve healthcare safety outcomes for a healthier bottom line. Mechanisms for the detection and improvement of fall prevention strategies will be critical as healthcare professionals keep pace with this enduring risk in a shifting healthcare environment.

References

Frank, J. R., Taber, S., van Zanten, M., Scheele, F., & Blouin, D. (2020). The role of accreditation in 21st century health professions education: Report of an International Consensus Group. BMC Medical Education, 20(S1). https://doi.org/10.1186/s12909-020-02121-5

Iorio, S. (2024, April 3). Falls prevention initiatives that make a difference. American Data Network. https://www.americandatanetwork.com/patient-safety/falls-prevention-initiative-that-makes-a-difference/

Najafpour, Z., Godarzi, Z., Arab, M., & Yaseri, M. (2019). Risk factors for falls in hospital in-patients: A prospective nested case control study. International Journal of Health Policy and Management, 8(5), 300–306. https://doi.org/10.15171/ijhpm.2019.11

The Joint Commission. (2021). Fall reduction program – Inclusion of all populations | Home Care | National Patient Safety Goals NPSG | The Joint Commission. Www.jointcommission.org. https://www.jointcommission.org/standards/standard-faqs/home-care/national-patient-safety-goals-npsg/000001602/

Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2020). Fall prevention practices and implementation strategies. Journal of Patient Safety, 18(1). https://doi.org/10.1097/pts.0000000000000758

van Wijck, S. F. M., Rizzo, C., Tsegai, N. S., Raybould, T., & Liu, S. W. (2019). Unexpected challenges to preventing falls in older adults: A mixed methods study of an emergency department-based falls prevention referral pilot project. Massachusetts General Hospital and Harvard Medical School. https://www.oatext.com/unexpected-challenges-to-preventing-falls-in-older-adults-a-mixed-methods-study-of-an-emergency-department-based-falls-prevention-referral-pilot-project.php#Article_Info

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As a risk manager, your job is to reduce the liability and risk associated with operating a health care organization, such as patient safety, branding perception, employee safety, etc. A huge part of this is thinking ahead and planning to avoid and reduce risk factors before they occur. By analyzing factors that influence risk management in the health care industry, you can be proactive and advise your organization on actions to take.

Risk Factors Report – Patient falls

Preparation
Choose one possible risk you may encounter in the health care industry. You are welcome to choose one of the following situations or choose a different situation with approval from your faculty member.

Release of HIPAA information
Mistake in surgery
Patient falls
Fraudulent billing
Profit losses due to the procedure or services

Assessment Deliverable
Write a 700- to 1,050-word report to the vice president of quality in which you:

Describe your chosen risk and an example scenario of how that risk could present itself.
Describe risk factors, internally and externally, that affect this risk.
Explain the role that accreditation standards and regulations play in addressing the chosen risk.
Analyze the challenges that addressing the risk may cause.
Explain how a risk manager will need to adjust and adapt to overcome these challenges and avoid future risks.
Analyze future trends (e.g., technology, staff changes) that may affect the risk and mitigate it in the future.