Fall Prevention Case Study

Executive Summary: Falls in the hospital are the major cause for the morbidity and the mortality in the elderly population. Falls among the elderly is increasigly being recognised and it is a major concern for the developed as well as the developing country. The purpose of this paper is to descibe the epidemiology of fall in the elderly in the hospital , incluidng the charateristics, circumstances and fall related related injuries. The focus of this program is to support the staff in identifying the system issues which gives rise to the error and the near miss situation. A quality improvement initiative was conducted to determine the effectiveness of a fall prevention program using education and a fall prevention kit
They are designed to assess the risk of falling. The categories which were chosen to prevent falls were multi factorial. The assessment was done in terms of exercise, environmental modifications and education. Few drugs are also said to be a component of this fall risk management.
The trend to advance patient safety and quality in health care organizations is based on implementing the concepts of high reliability organization. The core characteristics of the HRO have been well documented in the literature from the work of Weick and Sutcliffe (2001:2007). This is to reduce the system failure. The focus of a HRO is safe reliable performance. Weick and Sutcliffe ( 2001; 2007) described three types of unexpected events that require mindfulness to ensure to safe reliable performance.
1) When an event that was expected to happen fails to occur
2) When an event that was not expected to happen does happen
3) When an event that was simply un-thought of
The purpose of this study was to provide a data on the fall prevalence in a 27 month study. It is noted that the Medicare and the Medicaid Service rule does not reimburse hospitals for care related to injury as a result of the falls from the hospitals.
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The data was collected from the National database of Nursing Quality Indicators between the year 2006 and 2008. The patients were under observation for 88 million days and this data was taken from the Medical and the surgical units. A total of 315,817 falls were noticed during this study period. During the 27 month study, it was noted that the trend decreased to fewer falls. Table 1: Characteristics of hospitals (n=1,263) and nursing units (n=6,100) contributing information about patient falls to the NDNQI, July 1, 2006 – September 30, 2008. Table 2: The representation of the extent of injuries occuring in the Intensive care unit. Characteristics of hospitals (n=1,263) and nursing units (n=6,100) contributing information about patient falls to the NDNQI, July 1, 2006 – September 30,