Organizational Problem and Knowledge Gaps/Areas of Uncertainty NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis NURS-FPX 6212 Health Care Quality and Safety Management ​​​​​​​Quality and Safety Gap Analysis 

 

Patient falls within the healthcare settings are the most significant adverse events. These falls lead to various adverse consequences, such as injuries, fractures, internal bleeding, disease complications, and deaths. Approximately 1 million patients experience falls during their hospital stay in the United States (LeLaurin & Shorr, 2020). Almost 1/3rd of these falls are preventable (AHRQ, 2019). Various extrinsic risk factors lead to preventable falls in healthcare settings. Staffing shortages and burnout are common factors leading to quality and safety issues. According to Dall’Ora et al. (2020), understaffed units and provider burnout diminish the quality of care practices.

Consequently, this results in patient falls, medical errors, and adverse patient outcomes. Minimal assistance to patients, whether due to understaffing or inadequate resources, can exacerbate the risk of patient falls. Environmental issues within healthcare facilities, such as slippery floors, inaccessibility to facilities, low nurse-to-patient ratio, and overcrowding, also contribute to falling risk (Stathopoulos et al., 2021). 

Failure to address this issue leads to poor consequences such as increased healthcare costs, prolonged hospital stays, legal liabilities, undermined patients’ trust and satisfaction, and damage to institutional reputation. Several knowledge gaps and uncertainties persist, hindering comprehensive prevention strategies. Additional information is required related to the effectiveness of existing fall prevention interventions, the interplay between individual patient characteristics and environmental factors, and the role of emerging technologies in fall prevention. Thus, a comprehensive understanding of inpatient falls is imperative to improve patient safety in healthcare settings.

Practice Changes 

The practice gap in healthcare organizations stemming from insufficient preventive measures and ineffective patient safety management requires adequate practice changes. This gap leads to compromised quality and safety outcomes, as evidenced by the high prevalence of inpatient falls and associated injuries in the healthcare organization. The proposed practice changes are implementing comprehensive fall risk assessment protocols, staff education and training, and establishing an interdisciplinary fall prevention team. 

• Comprehensive Fall Risk Assessment Protocols: Standardized protocols for assessing fall risk upon admission and throughout the patient’s stay can help healthcare providers identify individuals at high risk of falls, guiding preventive measures. These protocols include using fall assessment tools like the Morse Fall Scale or Hendrich II Fall Risk Model. According to the Joint Commission International Accreditation (JICA) Standards for Hospitals, healthcare facilities should reduce the risk of patient falls by employing appropriate screening and assessment. Thus, standardized fall risk assessment tools are essential to stratify fall risk and guide tailored interventions (Strini et al., 2021). This proposed change assumes that regular fall assessment based on modifications in patient condition ensures proactive management of risk factors, reducing the likelihood of falls 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

• Staff Education and Training: Shaw et al. (2020) emphasize the importance of staff training and education in preventing fall incidences within healthcare settings. These educational interventions, integrating behavioral change models and theoretical frameworks, ensure changes in the quality of practices and reduce the likelihood of in-patient falls. It is presumed that increased awareness and knowledge of best practices can empower frontline caregivers for fall prevention. Ultimately, this will enhance patient safety and reduce adverse outcomes.

• Multidisciplinary Fall Prevention Teams: Interprofessional team members such as clinicians, pharmacists, physical therapists, and environmental specialists can leverage collective insights to tailor fall prevention interventions to individual patient needs, address environmental hazards and monitor outcomes. These teams foster collaborative efforts with diverse expertise to provide comprehensive patient care (Gemmeke et al., 2022). Assumptions underlying this proposal include the belief that interdisciplinary collaboration facilitates holistic assessment of patient safety risk factors, implementation of multifaceted interventions, and continuous quality improvement initiatives.  

Prioritization of the Proposed Change Strategies