Clinical/Organizational Problem According to the United States Department of Health and Human Services Agency for Healthcare Research and Quality (2018), between 700,000 and one million patients in the United States fall while in hospital each year, and about one third of these falls could have been easily prevented with effective administrative procedures and best practice protocols. Yet many organizations lack the quality and safety initiatives they need to prevent patient falls in hospital. As a result of negligence to prevent falls, patients experience a number of injuries that could even lead to higher mortality rates. Hospitals like this, which do not have fall preventing strategies in place, risk malpractice suits and fail to fulfill their ethical responsibilities to patients. Therefore, the organizational problem is related to insufficient—even nonexistent--fall prevention strategies.

Description of Problem

Falls occur at a rate of three to five per every 1000 bed stays, and are more prevalent in long-term care facilities (Patient Safety Network, 2018). The most significant consequences of falls include head trauma, bone fractures, and even death (Patient Safety Network, 2018). Even when a fall does not result directly in injury, it can seriously undermine patient trust in the healthcare team and perceptions of institutional quality of care (Patient Safety Network, 2018). Insurance providers and the Centers for Medicare and Medicaid Services do not reimburse hospitals for the “additional costs associated with patient falls,” (Patient Safety Network, 2018, p. 1). Given the tremendous ethical and financial costs associated with preventable falls, hospitals like this one need a comprehensive and immutable fall prevention strategy with the means by which to maintain a culture of safety throughout the organization.

Causes of the Problem

Falls are complex incidents, with several interrelated variables impacting patient risk. Patient factors in falls include age, muscle weakness or orthopedic issues, perceptual impairments, medications that may interfere with orientation, and chronic health conditions (Butcher, 2013). Contextual, situational, or environmental variables include lack of patient monitoring, slow response times to patient alerts, improper positioning of beds or furniture, or physical obstacles that increase risk including poor lighting or wet floors. While age may be a factor, though, not all falls are elderly patients and younger patients may be at even higher risk due to factors like being “embarrassed to ask for assistance or may put a higher priority on privacy than on safety,” (Health Research & Educational Trust, 2016, p. 14).

Explanation of Causes

In a comprehensive analysis of patient fall data, research shows that ineffective risk assessment is a contributing factor in preventable falls (Health Research & Educational Trust, 2016). Each patient should be considered a fall risk, “regardless of age or other factors,” (Health Research & Educational Trust, 2016, p. 14). Lack of patient alert systems, lack of patient education or awareness, and lack of staff training are some of the underlying causes of preventable falls, too. Administrative issues include the lack of staff training...

Administrators are particularly stakeholders in the change management processes that determine the future course of action for preventing falls. External stakeholders also include ancillary care providers that deal with the consequences of preventable falls, and other members of the patients’ healthcare team outside of the hospital. To a lesser degree, insurance providers may be considered stakeholders.
Stakeholders’ interest, power, and influence

Each stakeholder holds a different level of interest in any changes made within the facility. Administrators have the greatest power and influence on any proposed changes, and are in the position of evaluating a cost-benefits analysis of changes to policy and procedure. However, practitioners like physicians and nurses will also have a primary interest in how the changes are designed and implemented, as they will impact daily practice and patient interactions. Patients and their families are of course primary stakeholders but have little power in actually making the necessary changes to administrative design and organizational behavior. Yet patient perceptions can lead to problems like malpractice suits or loss of revenue over time, making patients and their families more powerful and influential over the long run. Likewise, the media and public relations strategies show how external stakeholders can wield indirect power on the healthcare organization.

Explanation of Project

The purpose of this project is to reduce falls and the risk factors associated with falls within this hospital. To address the root causes of preventable falls, the project will focus on leadership, communications, safety and quality protocol, physical environment and hospital design, and staff training. However, the project also requires a consistent and reliable means of measuring falls and risk factors, with metrics that offer honest insight into how well the proposed intervention works to reduce risk, severity, and prevalence of preventable falls. Also, how administrators classify falls will make a difference in the overall project. This project is also based on preliminary research showing that effective fall prevention strategies implemented at multiple levels of organizational design result in as much as a thirty percent reduction in preventable falls (Butcher, 2013).

Proposed Solution

The proposed solution to the problem of preventable falls includes a multifaceted, multidisciplinary intervention strategy. The strategy includes multiple areas of concern including leadership and managerial issues, human resources and quality assurance measures, communications, and physical design. The proposed solution engages patients and their families, too, empowering individuals with the knowledge they need to call nurses when risk factors may be high, or to safely navigate rooms or the institution to prevent falls. Training and ongoing assessment is also crucial for the effectiveness of the proposed fall prevention strategy in this hospital. This proposed solution is based on evidence related to best practices…