Leadership Learning Experience: In-Patient Falls (Essay Sample)

In-patient Falls
Leadership Learning Experience
Task 1
Student’s Name
C493 – Leadership and Professional Image
Instructor’s Name
Date
In-patient Falls
Issue or Problem
As a telemetry nurse, I have seen an increase in patient falls, and as a patient safety advocate, this coincides with my organization's values.
Explanation of the Issue
When one of our patients, particularly vulnerable to harm, has a fall, the hospital covers the cost of any necessary diagnostic imaging to identify injuries. The hospital covers the cost of any necessary medical care for the fall. Patients admitted to the telemetry unit often have a preexisting condition that puts them in a more fragile state than they are in while at home (Melnyk & Fineout-Overholt, 2019). This condition is due to weakness, syncope, shortness of breath, or anything else that puts them in a similar situation. A high incidence of falls leads to a rise in patient casualties and an increase in excessive charges that will not be reimbursed, thus, negatively influencing the organization's finances.
Investigation
Suppose a patient at the hospital has a fall; the nurse is responsible for assessing the patient, informing the provider of the incident, and placing orders for any required diagnostic tests that the physician has ordered. Afterward, the nurse updates the patient's electronic medical record with a post-fall evaluation and files an incident report into a different system. The nurse then notifies the charge nurse of the incident, and the charge nurse leads a post-fall huddle with the staff working on that floor at the time. During the huddle, they discuss what caused the fall or how it can be avoided in the future (Melnyk & Fineout-Overholt, 2019). The charge nurse compiles a monthly and quarterly report on several safety concerns, including falls. At every staff meeting, we review any falls that have occurred since the previous meeting, the likely underlying causes, and any interventions that lessen the likelihood of future falls.
Evidence of Issue or Problem
According to the charge nurse, the telemetry unit recently recorded a rise in falls during the past quarter. With each fall review, I raised the question of whether we were staffed according to the matrix. This reason has not caused falls over the last year. Only one fall occurred when we were staffed below matrix. We have 29 falls so far for the current fiscal year.
Analysis
In the previous year, the hospital recorded 29 patient falls as categorized below;
* Ten falls = alarms went off, and we did not get there in time
* Nine falls = we assisted the patient to the floor
* Five falls = bed alarm was left off when it should have been on
* Two falls = patients were just non-compliant and refused safety protocol
* Two falls = low risks just accidentally fell
* One fall = Unwitnessed bed alarm did not need to be on
With the ten falls, I am unsure if the delay in getting to the patient contributed to the fall. We witnessed alarm fatigue that could result from not hearing alarms in the COVID room. There would be a difference if we used a gait belt for the nine assisted falls. The bright note is that assisting the patient to the floor possibly prevented injury.
Contributors to Issue or Problem
The Johns Hopkins fall risk assessment instrument is used to capture each patient's potential for falling and keeping it in the medical record. When a patient is at high risk for falls, the caregiver will first obtain a fall risk packet from the supply room. This packet will include non-slip socks, a fall risk armband, and a leaf on the door to the patient’s room to alert other staff members that the patient is at a fall risk (Centre for Disease Control, 2017). This process is guided by a health educational brochure regarding fall reduction and fall risk. Patients are instructed to alert the nurse and request help before attempting to get out of bed. If necessary, the escape alarm incorporated into the bed itself is activated. Here, we use any of the unit's five magnetic pull tab alarms. In addition, the nurse and the patient care assistant (PCA) work together to boost patient rounding. This initiative helps to guarantee that the patient never has to get out of bed by themselves and that the call bell is within reach.
Patient falls increase when the patient does not wear non-slip socks. They get tangled in IV lines and cannot get out of bed. These incidences occur because the surfaces are cluttered, the bulbs are inadequate, or the call bells are dropped, so they cannot ask for help. In many cases,