Patient falls is an area that our facility is always working to improve on. Falls are the most frequently reported patient safety concern in a hospital setting (Morris and O’Riordan, 2017). Falls are tracked and trended through our incident reporting system and is a measurable patient-centered safety concern that can be improved. As the Risk Manager, it is my responsibility to review trends, determine if there are deviations in policy and procedures, and empower our Directors to educate their care team members on our policies and procedures. Yearly education is provided on safe practices, policy and procedures, and ways care team members can prevent patient falls. As part of the quality team, we make rounds on the units to make sure our care team members are following policies intended for patient safety.
Preventative falls are falls that could be prevented if facility policies and procedures are followed and these falls were chosen because we have noted an increased trend in preventable falls. Per Goldsborough (2019), there is a high incidence of falls during patient toileting. A interview with the Medical Surgical Director was conducted. There have been multiple falls among high risk fall patients during patient toileting. We have recently had a patient that triggered high risk fall precautions and was left alone on the toilet for privacy. This patient attempted to get up unassisted and fell and broke his hip. Our policy states patients that are high risk falls are not to be left alone during toileting. More investigation will be spent on falls during toileting to see if we can decrease these falls. The interview sparked particular concern with care team members not following the fall policy and we felt additional concentration should be spent to address why care team members leave patients and how we can change heir perspective on patient safety.
Discussion question 2:
Patient safety is a crucial component of positive patient outcomes. The most common cause of injury is from adverse drug events (ADEs) due to medication errors. ADEs can originate from various stages in the administration process. Barcode scanning within hospital settings has been shown to reduce the rate of medication administration errors by 85% with little negative impact on nursing workflow. Even though recent studies reveal the positive influence barcode scanning can have on reducing ADEs, often, the implementation can lead to staff revolt, stopping of the project altogether, and poor patient outcomes (Nanji et al., 2009).
Barcode scanning has been implemented in my workplace setting over the past two years; however, ADEs still occur despite the increasing compliance of medication scanning. An explanation as to why ADEs are again arising may be from the nature of the emergency setting. The fast-paced workflow and high acuity of patients appear to be critical factors in not scanning medications and the rate of ADEs. I chose to focus my project on medication scanning, ADEs, and perceived nursing barriers. Various data is available regarding medication administration. The reports can decipher the percentages of medications being scanned, the names of the medicines, as well as who scanned them and when. Also, data is available regarding ADEs and why they occurred through the event reporting system; however, medication errors are often underreported (Hung et al., 2016).