MSN FPX 6016 Med Adverse Event or Near Miss Analysis KP
As we all know nurses can get very busy in the hospital. When this happens, adverse events increase drastically. I remember as a nurse on the telemetry unit, a sweet elderly lady had fallen under my care. Her name was Miss F, a 68-year-old wife that recently got admitted to the hospital. She had a medical Hx of Alzheimer’s, and her husband visited quite often. She also had Arthritis, CHF, and current urinary frequency. Her medications were Lisinopril, Lasix, and Seroquel. She has had problems of stability and falls often. While her husband was away from her bedside, Miss F attempted to get out of bed to use the bathroom- That is when the fall occurred. Many missed steps and protocol deviations happened in this adverse event that could have been prevented. This includes patient safety, hourly rounding not completed, and not assessing her personal hazards related to her medical history. Although I was very disappointed with the way I missed the fall, I have implemented new steps to prevent future falls- this will be discussed throughout this analysis.
Every year, between 830,000 and 1.1 million people in the US experience an adverse event fall in the hospital (Fulbrook & Gettens, 2018). These falls can be minor and may result in lacerations. Others can be more serious like fractures or internal bleeding to the head or organs. When this occurs, health care utilization are increased, potential leaving the hospital to pay for the fall occurrence. Research indicates that close to 35% of falls can be prevented in the hospital (Fulbrook & Gettens, 2018). The prevention of falls should cover the management the patient’s underlying risk factors of falling- it should also have a goal to improve the physical environmental and design of the hospital. This adverse risk analysis will focus on overcoming any problems associated with making, applying, executing, and sustaining a fall successful prevention program (Fulbrook & Gettens, 2018). As of 2008, (CMS) Centers for Medicare & Medicaid Services will not reimburse any hospitals for specific types of traumatic injuries that happen while the patient is hospitalized. This is a big problem for the patient, hospital, and its stakeholders.
Fall prevention requires a collaboration approach of care between the patients’ personal needs and a concise effort from the hospital. Many core parts of fall prevention care are standard; other features should be tailored for the patient’s detailed risk factors of falling. Let’s be honest, no healthcare professional working by themselves, regardless of how skilled they are, can avoid every patient fall. Rather, fall prevention needs to have an active engagement of every individual on the healthcare team including the doctor, RN, LVN and certified nursing assistant. It should also include a sustained plan implemented by the hospital in caring for the patient (Dolan & Sebach,2020). To achieve this goal, the best fall prevention plan should have organizational principles and operational applications that encourage strong communication and teamwork, as well as professional know-how. Fall prevention methods also need to be well-adjusted with other thoughts and actions, such as trying to not order restraints for patients if they are confused, agitated, or noncompliant. The goal should never try to decrease the patients’ mobility, but to provide the best possible care to the patient in a safe and effective way. An evidence-based practice on how to improve fall prevention will require a sound system to focus on every patient need. Determined patient rounding by every healthcare professional should be hands-on, organized, and nurse driven. Efficient patient rounding involves the nursing staff to check on their patients at steady intervals and to implement the “5 P’s. Numerous studies done on purposeful rounding exhibit its effectiveness on fall preventions, showing a significant decrease in falls at hospital facilities (Dack & Roe, 2019).
The 5 Ps contain patient-focused questions to ask that mee the essential needs of the patient:
As we all know nurses can get very busy in the hospital. When this happens, adverse events increase drastically. I remember as a nurse on the telemetry unit, a sweet elderly lady had fallen under my care. Her name was Miss F, a 68-year-old wife that recently got admitted to the hospital. She had a medical Hx of Alzheimer’s, and her husband visited quite often. She also had Arthritis, CHF, and current urinary frequency. Her medications were Lisinopril, Lasix, and Seroquel. She has had problems of stability and falls often. While her husband was away from her bedside, Miss F attempted to get out of bed to use the bathroom- That is when the fall occurred. Many missed steps and protocol deviations happened in this adverse event that could have been prevented. This includes patient safety, hourly rounding not completed, and not assessing her personal hazards related to her medical history. Although I was very disappointed with the way I missed the fall, I have implemented new steps to prevent future falls- this will be discussed throughout this analysis.
Every year, between 830,000 and 1.1 million people in the US experience an adverse event fall in the hospital (Fulbrook & Gettens, 2018). These falls can be minor and may result in lacerations. Others can be more serious like fractures or internal bleeding to the head or organs. When this occurs, health care utilization are increased, potential leaving the hospital to pay for the fall occurrence. Research indicates that close to 35% of falls can be prevented in the hospital (Fulbrook & Gettens, 2018). The prevention of falls should cover the management the patient’s underlying risk factors of falling- it should also have a goal to improve the physical environmental and design of the hospital. This adverse risk analysis will focus on overcoming any problems associated with making, applying, executing, and sustaining a fall successful prevention program (Fulbrook & Gettens, 2018). As of 2008, (CMS) Centers for Medicare & Medicaid Services will not reimburse any hospitals for specific types of traumatic injuries that happen while the patient is hospitalized. This is a big problem for the patient, hospital, and its stakeholders.
Fall prevention requires a collaboration approach of care between the patients’ personal needs and a concise effort from the hospital. Many core parts of fall prevention care are standard; other features should be tailored for the patient’s detailed risk factors of falling. Let’s be honest, no healthcare professional working by themselves, regardless of how skilled they are, can avoid every patient fall. Rather, fall prevention needs to have an active engagement of every individual on the healthcare team including the doctor, RN, LVN and certified nursing assistant. It should also include a sustained plan implemented by the hospital in caring for the patient (Dolan & Sebach,2020). To achieve this goal, the best fall prevention plan should have organizational principles and operational applications that encourage strong communication and teamwork, as well as professional know-how. Fall prevention methods also need to be well-adjusted with other thoughts and actions, such as trying to not order restraints for patients if they are confused, agitated, or noncompliant. The goal should never try to decrease the patients’ mobility, but to provide the best possible care to the patient in a safe and effective way. An evidence-based practice on how to improve fall prevention will require a sound system to focus on every patient need. Determined patient rounding by every healthcare professional should be hands-on, organized, and nurse driven. Efficient patient rounding involves the nursing staff to check on their patients at steady intervals and to implement the “5 P’s. Numerous studies done on purposeful rounding exhibit its effectiveness on fall preventions, showing a significant decrease in falls at hospital facilities (Dack & Roe, 2019).
The 5 Ps contain patient-focused questions to ask that mee the essential needs of the patient:
Stakeholder Involvement
The implications of the fall adver
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