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NURS FPX6410 Assessment 3 Exploration of Regulations and Implications for Practice

Exploration of Regulations and Implications for Practice

The focus of this study is to implement a fall prevention program that is suggested for the administration of City Hospital, New York, in the previous assessment. The program aims to improve patient safety by reducing the incidence of falls and ultimately decreasing healthcare costs associated with fall-related injuries. To ensure a successful implementation, the program will employ a comprehensive approach using the PDSA model, a HIPAA-compliant spreadsheet, evidence-based guidelines, data trending, and regulatory compliance. The PDSA model will enable us to test our interventions and incorporate feedback for continuous improvement (Minnesota Department of Health, 2019). A HIPAA-compliant spreadsheet will help securely protect patient confidentiality. We will also incorporate evidence-based guidelines and standards of practice established by national organizations such as the Joint Commission and CDC. Data analysis will be conducted regularly to identify fall-related trends and patterns. The program’s effectiveness will be measured by establishing baseline data and comparing progress. Regulatory information that supports informatics and is adhered to other compliances. By taking this comprehensive approach, we can ensure the effectiveness and efficiency of the fall prevention program and ultimately improve patient safety for this vulnerable patient population.

NURS FPX6410 Assessment 3 Exploration of Regulations and Implications for Practice

Safety Issue Involved in the Incidence of Fall

Falls among patients is a significant safety issue for City Hospital, New York. According to recent statistics, falls account for more than half of all patient injuries, and patients over 60 are at an increased risk of falling (Appeadu & Bordoni, 2022). The consequences of falls are severe and can include fractures, head injuries, and even death (Vaishya & Vaish, 2020). For this reason, hospitals like City Hospital must implement measures to reduce the occurrence of patient falls and boost overall patient security.

Recently, an elderly patient named Mrs. Smith was admitted to City Hospital after a fall in her home. She suffered a hip fracture, and due to her age and medical history, surgery was deemed too risky. Therefore, Mrs. Smith had to undergo a prolonged recovery period, during which she experienced severe pain and discomfort. Furthermore, she developed complications such as pneumonia, further delaying her recovery. The fall and its subsequent complications significantly reduced her quality of life and increased her healthcare costs.

The case of Mrs. Smith highlights the need for proactive measures to prevent falls. Several risk factors contribute to falls, including medical conditions, medications, and environmental factors. Therefore, a comprehensive fall prevention program must address all these factors.

One crucial step in preventing falls is to conduct a fall risk assessment upon admission. This assessment will identify patients at risk of falling and allow for targeted interventions. The assessment should consider the patient’s medical history, medications, and mobility status. Based on the assessment results, interventions such as bed alarms, non-slip footwear, and mobility aids can be implemented. In addition to targeted interventions, environmental modifications can also prevent falls. Hospital staff should ensure that floors are dry and clutter-free, adequate lighting, and handrails are available in all necessary areas. Patients should also be educated on fall prevention strategies and encouraged to call for assistance when needed. It is essential to track and analyze fall-related data to understand the effectiveness of fall prevention programs. This data can identify trends and patterns, allowing for continuous improvement and refinement of fall prevention strategies.

Stakeholders Involved

The implementation of fall prevention involves multiple stakeholders. The stakeholders include hospital administrators, healthcare providers, patients, families, and regulatory bodies.

Hospital administrators play a crucial role in the implementation process. They provide resources and support to ensure the program’s success. This includes allocating funding for training and equipment and establishing policies and procedures to ensure compliance with regulations. Meanwhile, healthcare providers are another critical stakeholder group. They are responsible for identifying patients at risk for falls, implementing prevention strategies, and monitoring patient outcomes. They must be trained in evidence-based guidelines and standards of practice to ensure that they provide the highest quality of care to patients over 60.

Furthermore, patients and their families are also stakeholders in the implementation process. They must be informed about the fall prevention program and its role in preventing falls. Patients must be encouraged to participate in their care actively, follow instructions from healthcare providers, and report any concerns or incidents promptly.

In addition, regulatory bodies such as the Joint Commission and Centers for Disease Control and Prevention are also stakeholders. They establish guidelines and regulations for healthcare facilities to ensure patient safety and quality of care. Compliance with these regulations is critical to the success of the fall prevention program.

Intended Goal of the Initiative

The fall prevention program aims to reduce falls and improve patient safety for patients aged 60 and over. Falls are a major cause of injury for this age group, resulting in reduced quality of life, higher healthcare costs, and increased mortality rates. The program will use the Plan-Do-Study-Act (PDSA) model to test interventions and continuously improve based on feedback. It will also create a secure HIPAA-compliant spreadsheet to store patient data, monitor and analyze fall-related data, and use evidence-based guidelines to inform fall prevention strategies. Baseline data will be established and regularly measured to track progress, and regulatory compliance will ensure the highest level of safety for patients.

NURS FPX6410 Assessment 3 Exploration of Regulations and Implications for Practice

Analyzing the Initiative

To assess the impact and effectiveness of a fall prevention initiative, it is important to evaluate its compliance with regulations, ethical principles, and safety standards, including the use of evidence-based guidelines, the Plan-Do-Study-Act (PDSA) model, and adherence to regulatory bodies such as HIPAA, as well as ethical considerations such as patient confidentiality and informed consent. Measuring the program’s success in reducing falls and improving patient outcomes can also provide a comprehensive assessment of its impact and effectiveness. By analyzing a fall prevention initiative from various perspectives, we can better understand its impact and determine its success in achieving its goals.

Safe Practices

To ensure adherence to safety standards and regulations, analyzing the fall prevention intervention involves implementing evidence-based guidelines and using the PDSA model (Gonzalez, 2021). In addition, the program ensures patient confidentiality and safety by utilizing a HIPAA-compliant system to store and restrict access to data and regularly monitors and analyzes fall-related data to track progress and identify areas for improvement.

Ethical Considerations

It is essential that the program adheres to ethical values like beneficence, non-maleficence, and fairness while treating patients (Ahmed et al., 2020). In the case of the fall prevention program, ethical considerations may involve ensuring that patients are fully informed about the program, their rights, and options and that their privacy and confidentiality are protected (Olejarczyk & Young, 2022). Additionally, the program should ensure that patients are not subjected to unnecessary risks or harm and that potential conflicts of interest are identified and addressed appropriately. Ethical considerations should also include ensuring that the program is accessible and equitable and that it does not discriminate against any patient population.

Regulatory Considerations

When analyzing a fall prevention intervention using regulatory considerations, evaluating the program’s compliance with legal and regulatory requirements is essential. For instance, the fall prevention program recommended for the City Hospital in New York should comply with HIPAA and OSHA regulations (Mitchell, 2020). The program should ensure patient confidentiality and train healthcare workers to provide safe care. Additionally, all equipment and facilities should comply with regulatory requirements to minimize fall risks and other safety hazards. Regular audits and assessments can help identify areas that need improvement and ensure ongoing compliance with regulatory requirements.

Standard of Practice

It is crucial to evaluate adherence to the standards of practice in using technology to improve patient care, including compliance with HIPAA and ANA Nursing Informatics standards (Strudwick et al., 2019). To ensure compliance, the program must manage and store patient data securely and train healthcare workers to use technology safely and effectively for patients over 60. Furthermore, it should ensure that any software or equipment used complies with regulatory requirements and is compatible with existing systems to minimize errors and enhance efficiency.

Analyzing the Initiative Using PDSA Model

The Plan-Do-Study-Act (PDSA) model is a quality improvement framework used in healthcare to implement and evaluate interventions. When applied to the fall prevention intervention, the model can help identify areas for improvement and ensure that the program effectively reduces falls.


In the planning stage, the fall prevention program should define its objectives and goals, identify the target population, and determine the resources required to implement the program. The program should also identify potential barriers and challenges hindering its success. In our case, it is the identification of the patients prone to falls.

NURS FPX6410 Assessment 3 Exploration of Regulations and Implications for Practice


In the implementation stage, the fall prevention program implements the plan, including training healthcare workers and implementing the necessary technology and equipment. This includes using patient monitoring systems, medication management software, and other technologies to help reduce the risk of falls.


In the study stage, the fall prevention program evaluates its effectiveness in reducing falls. This involves collecting and analyzing data, including patient outcomes and satisfaction, staff compliance, and adverse events.


In the act stage, the fall prevention program acts based on the results of the study phase. This involves adjusting the program to better meet the needs of patients, staff, and other stakeholders. It also involves modifying policies or procedures to improve patient safety and outcomes.

In nursing informatics, the PDSA model identifies and evaluates the use of technology and informatics solutions to improve patient care and safety. The PDSA model helps to ensure that technology is implemented effectively and that any issues or concerns are addressed promptly and effectively.


This study focused on the patient falls issue in detail. The case study of the project was City Hospital, where the incidents are frequent. Based on the above discussion, it has been concluded that the hospital administration must employ thorough guidelines and policy implementation processes to prevent falls. In this regard, the PDSA model is significant in ensuring technology implementation, smooth processing, and effective execution. 


Ahmed, A., Saad Ali, H., & Mahmoud, M. (2020). Prioritizing well-being of patients through consideration of ethical principles in healthcare settings: Concepts and practices. Systematic Reviews in Pharmacy, 11(5). https://www.sysrevpharm.org/articles/prioritizing-wellbeing-of-patients-through-consideration-of-ethical-principles-in-healthcare-settings-concepts-and-pract 

Appeadu, M., & Bordoni, B. (2022, February 22). Falls and Fall Prevention. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560761/ 

Gonzalez, R. (2021). Improving fall risk assessment in primary care using an evidence-based fall prevention protocol. https://www.doctorsofnursingpractice.org/wp-content/uploads/project_form/complete_181021065333 

Minnesota Department of Health. (2019). PDSA: Plan-Do-Study-Act (Rapid Cycle Improvement). State.mn.us. https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/pdsa.html 

NURS FPX6410 Assessment 3 Exploration of Regulations and Implications for Practice

Mitchell, A. H. (2020). Occupational Safety and Health Administration (OSHA) Regulatory Compliance. Preventing Occupational Exposures to Infectious Disease in Health Care, 51–66. https://doi.org/10.1007/978-3-030-56039-3_5 

Olejarczyk, J. P., & Young, M. (2022). Patient rights and ethics. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538279/ 

Strudwick, G., Booth, R. G., Bjarnadottir, R. I., Rossetti, S. (Collins), Friesen, M., Sequeira, L., Munnery, M., & Srivastava, R. (2019). The role of nurse managers in the adoption of health information technology. JONA: The Journal of Nursing Administration, 49(11), 549–555. https://doi.org/10.1097/nna.0000000000000810 

Vaishya, R., & Vaish, A. (2020). Falls in older adults are serious. Indian Journal of Orthopaedics, 54(1), 69–74. https://doi.org/10.1007/s43465-019-00037-x 


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