Question

Use the QSEN competencies to fix the problem. Be creative. Thinking critically and in a manner that will avoid this from happening in the future.

Problem: Patient fell while trying to ambulate to bathroom without his walker and suffered a brain bleed (FALLS).

Answer 1

QSEN will take following measures to avoid future fall.

1) Universal Fall precautions including timely round protocol.

2) Standardized assesment for risk factors of fall.

3) Making a  care plan for the identified risk factors of the patient.

4) Post fall procedure

1) Universal Fall precautions including timely round protocol.

   Some of the points are

a) Familarize the patient to the environment

b) Maintain the call bell within the reach of ppatient and ask patient to demonstrate .

c) Keep all the patients personal belongings within the reach.

d) Have a sturdy hand rails in the room of patient including bath room

e) Hospital bed should be kept locked.

f) Wheel chair wheel should be kept locked when not in use.

g) Use of night light.

f) Keep floors dry and clean.

g) Maintain safe patient handling practise.

2) Standardized assesment for risk factors of fall.

For this QSEN uses Morse fall Scale. I am attaching the morse fall scale along with this.

Patient's Name ....PRN... Unit. ...... ........Date..... Time Fall Risk is based upon Fall Risk Factors. Determine Fall Risk Factors and Target Interventions to Reduce Risks.. Complete on admission, at change of condition transfer to new unit, and after a fall. Score Variables Date History of Falling Yes Secondary Diagnosis No 15 0 Ambulatory Aid Yes None/bed rest/nurse assist Crutches/canelwalker Furniture 15 No IV or IV access/ On CNS/CVS medicines (HCTZ, ACE inhabitors, Ca channel Blockers, a blockers etc.) Yes Gait Normal/bed rest/wheel chair week impaired knows own limits Overestimates of forgets limits Mental status 15 Total Score N.B.: <25-Low risk 25 - 45: Moderate risk > 45: High risk Signature with Emp. ID. Score reviewed by Definition of Patients FALL a NABH mandatory QI :-Loss or upright position that results in landing on the floor, ground or an object or furniture or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor ground or hitting another object like chair or stair, it is an event that results in a person coming to rest inadvertently on the ground or flooror other lower level.

3) Making a care plan for the idenfied risk factors of the patient.

It includes the risk factors we are getting from the standardized assesment and making a care plan to prevent fall. Some of the common risk factors are

a) Altered mental status

b) Impaired gait or mobility

c) Frequent toilet needs.

d) Visual impairment

e) Patient on high alert medication

f) Have a history of frequent falls

4) Post fall procedure.

Which include clinical review and root cause analysis. Clinical review ensure continued delivery of optimal patient care and patient safety followed a fall. Root cause analysis identifies which all are the events and how to rectify it.