Now, we will discuss how the existing organizational functions, procedures, norms, policies, and staff behaviors affect the quality of care and patient safety within our organization, significantly augmenting in-patient fall rates. The lack of comprehensive fall risk assessment procedures is a primary organizational lapse that increases in-patient falls. For instance, inconsistent fall risk assessment protocols may result in missed opportunities to effectively identify and address patient fall risks (Appeadu & Bordoni, 2023). Additionally, environmental factors such as inadequate lighting and crowded walkways are hazardous practices within the organization, heightening fall risk for high-risk patient populations. Similarly, behavioral inefficiencies of communication gaps among health providers and lack of staff adherence to fall prevention strategies increase the likelihood of in-patient falls. This results from insufficient practices and coordination failures (Turner et al., 2022).
Addressing these aspects can contribute to building reliability and high-performing organizations by focusing on several key strategies, such as standardizing fall risk assessment protocols and ensuring comprehensive staff training on fall prevention strategies. Secondly, creating a sense of accountability and continuous learning by fostering open communication channels and interdisciplinary collaboration among healthcare teams. Additionally, making environmental modifications to create safer care environments and mitigate fall risk factors (Stathopoulos et al., 2021).
Knowledge Gaps and Areas of Uncertainty
Despite knowing the organization’s functions and behaviors impacting quality and safety, there remain knowledge gaps and areas of uncertainty. The knowledge gaps exist related to the best practices that have positively affected the organization. There are uncertainties surrounding the optimal utilization of technology in identifying fall risk factors and guiding preventive measures. Moreover, there are unanswered questions regarding the leadership commitment to fostering a safe and supportive environment for fall prevention efforts. Addressing the knowledge lapses will result in the effective implementation of the proposed plan.
Enhancing the quality of care and patient safety culture is continuous, requiring ongoing monitoring and evaluation. Thus, the organization should focus on particular outcome measures to collect quantifiable data on in-patient falls and develop interventions accordingly. These outcome measures are fall rates, fall-related injuries, and costs. Here, we will discuss these outcome measures, elaborating on their strengths and weaknesses.
Fall Rates
The numerical data that evaluates the number of falls per patient day in a patient population for a specified time is called the fall rate (AHRQ, n.d.). This outcome measure is advantageous as it enables the organization to monitor fall patterns, recognize high-risk patients, and monitor the effectiveness of fall prevention errors. Yet, its weakness is that its accuracy depends on precise reporting and may encounter variations due to underreporting.
Fall-Related Injuries
Kenis et al. (2022) emphasize that fall-related injuries are a valuable outcome measure for assessing the severity of in-patient falls. This outcome measure is substantial as it helps identify the damage caused by in-patient falls, guiding the need for more sustainable and robust preventive interventions. However, a limitation of this measure lies in the inconsistency and variability in reporting and categorizing injuries. Fall-related injuries may result in less reliable data, necessitating a nuanced data collection and analysis approach.
Cost
This outcome measure evaluates the financial impact of inpatient falls. Assessing the cost of inpatient falls is valuable as it helps organizations plan resource allocation and invest in more comprehensive fall prevention efforts (Ağartioğlu Kundakçi et al., 2020). Nevertheless, this outcome measure challenges the stakeholders to identify the sole reason for healthcare costs, as additional expenditures may be associated with other factors.
I will elaborate on the steps needed to improve outcomes through each practice change described earlier.
Comprehensive Fall Risk Assessment Protocols
The steps in standardizing fall risk assessment protocols include reviewing the existing fall risk assessment tools and protocol
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