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MSN FPX 6016 Med Adverse Event or Near Miss Analysis KP

Patient Falls in the Hospital- Adverse Event Analysis

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. 

Patient Falls and Workarounds

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:

  •  Pain: Ask the patient their pain level and address if elevated. 
  • Potty: Ask if patient if they need to use the restroom- possible needing assistance.
  • Position: Ask the patient if they are feeling relaxed a comfortable, possible needing repositioned.
  • Personal needs: Ensure that all personal belongings are in reach, next to the bedside table. Make sure the call light is close to the patient- or at least close by. 
  • Presence- Make frequent rounding and answer the call light in a timely manner. Communicate with the patient that if they need something.

Stakeholder Involvement

The implications of the fall adverse event with Miss F. showed detrimental effects to all involved, especially the stakeholders. The patient is harmed, possibly causing the hospital or clinic a longer stay-at the hospital the facilities expense. Key responsibilities of stake holders in the hospital setting are to provide patient safety, avoid harmful events, and utilize all resources at an economic price. The Stakeholders responsibilities are to also support and provide funding, administrative support, strategic direction, resolutions and more to the general healthcare business (Auerbach et al., 2021). The all-encompassing goal of any successful fall prevention plan is to establish feelings of safety, security, and confidence in the information of the patient’s physical abilities and limitations. In Miss F. case, education will have to be given to the husband, due to her Alzheimer’s diagnosis.  When patients and their family members feel knowledgeable and in control, they are more likely to contribute to the fall prevention trainings

MSN FPX 6016 Med Adverse Event or Near Miss Analysis KP

To have better results for fall prevention, both short-term and long-term goals should be in motion. Here are some essential goals that can help with decreasing falls in the hospital care setting (Auerbach et al., 2021). It is also important to review all data on the success or failure of the program, this will give us vital data if the plan needs to be modified or changed. 

Short term: 

Goal 1- Completing a fall risk assessment every shift for every patient on the floor.

Goal 2- The use of assistive equipment like a gait belt when lifting or walking a patient.

Goal 3- Fall risk signs that are visible from the hallway of the patient’s room.

Goal 4- Patient wristband that state “Fall Risk”.

Goal 5- Patient always has on nonskid footwear.

Long term: 

Goal 1- Shape and configure policies and systems to support fall prevention. 

Goal 2- Grow awareness about fall prevention for patient and staff.

 Goal 3- Improve fall prevention in the hospitals with implementations. 

Goal 4- Improve fall prevention in healthcare settings.

Effective fall prevention programs contain an assortment of stakeholders who may have diverse expectations and perceptions of any successful fall prevention plan. To safeguard that good evaluation results will match the stakeholder goals, it is vital for administration and staff spend time to understanding the different stakeholder frame of reference and participate in the evaluation. This will create a team that brings a wide variety of ideas to the table (Auerbach et al.,2021). It is beneficial to involve stakeholders with wide-ranging skills and positions for evaluation tasks such as developing a strong plan, collecting data, spreading the results-both positive and negative, collection of surveys from the patients, and revising evaluation discrepancies. Fall prevention stakeholders can include nurses, health information technology (IT), community leaders, fall prevention champions, healthcare providers, funding agencies, patients, family members, state and local health department staff, caregivers, healthcare professionals, policy creators, and official leaders.

MSN FPX 6016 Med Adverse Event or Near Miss Analysis KP

Fall prevention stakeholders are individuals or administrations that:

  • Start or continue fall prevention programs- Champions, nurses, and healthcare providers.
  • Are involved in fall prevention strategies and actions- Physical therapy, occupational therapy, RN, LVN, CNA.
  • The patients that are affected by the fall prevention program- Patients
  • Companies or organizations that will use the results of the evaluation- Funding agencies like Medicare & Medicaid Services, hospitals, IT agencies.

Quality Improvement Fall Prevention Technologies 

Another method that will help decrease the occurrence of patient falls in the hospital is to utilize Communications system called the CareView. This program is for fall prevention management and it uses video observation technology which proposes a strategy to avoid patient falls by tailoring patient rounding, conducting fall risk assessments, and producing survey reports (Stanford, 2019). Steered by Donabedian’s framework, this project assessed the effectiveness of the application of CareView video monitoring the reduction falls, evade falls with minor or major injury, and decrease use of the nursing staff on the hospital’s medical-surgical and telemetry units. About 13 months into the implementation fall data, it was also compared to 12 months of follow up implementation data to gauge the video monitoring (VM) systems efficiency in fall decrease. There was a decrease in the number of falls on the medical-surgical (5.08 to 2.81/1,000 patient days) and the telemetry (3.81 to 0.84/1,000 patient days) units, the outcome showed statistically improvements. The outcomes of this project could help positive social change by helping to determine the effectiveness of the CareView system in decreasing falls and recognizing strong approaches for applying the use of the VM system to decrease patient falls and improve patient safety.

Quality Improvement Strategies

In the setting of the hospital, falls continue to be one of the highest adverse event and injuries from falls are often linked with mortality and morbidity. A substantial body of evidence-based practice writings exists on the prevention of falls and reduction. Effective prevention strategies include recognizing patients at high risk for sustaining serious injury from a fall, multifactorial assessment (assessing hazards of falling based on known fundamental and relative factors), interventions (protective action to adapt and compensate for risk factors), and methodical reporting of falls occurrences and their penalties (Dack & Roe, 2019). Many involvements to avoid falls and fall-related grievances require multidisciplinary support for dependable implementation for detailed at risk and vulnerable demographics, such as the elderly and those at risk for injury like confused patients. All energies must be made to confirm that patient safety plans are in place across all situations of care.

MSN FPX 6016 Med Adverse Event or Near Miss Analysis KP

Here are some Evidence-Based practice quality improvement strategies for all prevention, these strategies should be implemented in the hospital to reduce falls:

  • The call light within reach the patient always
  • Personal are within the patient’s reach.
  • hourly rounding by every nurse assigned to the patient.
  • Notifying the patient is on fall risk precautions and anticipated adherence.
  • 5 Ps: pain, positioning, personal items, potty, and prevention


Patient safety is one of the top priorities for all healthcare professionals and healthcare providers. Healthcare professionals in acute care hospitals have a multifaceted and possibly conflicting set of goals when taking care of patients. Hospital employees need to treat the diagnosis, sustain patient safety, and help the patient recover mental and physical function. Consequently, fall prevention must be well-adjusted and stable against other priorities. Fall prevention contains managing a patient’s important subsequent fall risk factors such as medication side effects, generalized confusion, difficulties with transfers and walking, medical equipment like I.V poles, and frequent needs of toileting (Dack & Roe, 2019). Multiple hospitals and healthcare facilities have been shown to decrease the incidence of falls, but these fall prevention applications are not used steadily hospitals.


Auerbach, G. & Good, G. & Rivera, A. J. (2021). Working with healthcare subject matter experts and clinical stakeholders. Comprehensive Healthcare Simulation, 207-210. 10.1007/978-3-030-72973-8_27

Dack, R. & Roe, L. (2019). Changing practice – A quality improvement project. Quality Improvement; Embedding a culture of quality improvement. 10.1136/archdischild-2019-rcpch.34

Dolan, C. & Sebach, A. M. (2020). Using institute for healthcare improvement open educational resources in DNP quality improvement courses. Nurse Educator, 46(2), 75-75. 10.1097/nne.0000000000000888

Fulbrook, P. & Gettens, S. (2018). Fear of falling: Association between the modified falls efficacy scale: In hospital falls and hospital length of stay. Journal of Evaluation in Clinical Practice, 21(1), 43-50. 10.1111/jep.12226

Rogers, G. (2017). Benefits of interprofessional collaboration in healthcare.        Tiger Connect. https://tigerconnect.com 

Stanford, M. (2019) Reducing patient falls and decreasing patient safety: Attendant utilization with CareView communication technology (2019). Walden Dissertations and Doctoral Studies. 7081.


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