Post on 19-Aug-2014
description
transcript
Reduce the Risk of Patient Harm
Resulting from Falls
Objectives By the end of this presentation the participant will be able to:
Define the patient fall List the factor contributing towards
fall Discuss the importance of patient’s
assessment and assessment criteria. Implement the specific nursing
intervention for fall prevention Manage patient after falls Aware about the patient fall
prevention program
Fall “A fall is considered an unintentional event that results in a
person coming to rest on the ground or other lower level.” (www.UTHCPCProcedures - Fall Prevention and Management
Program.mht) “Fall: loss of 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 a chair or stair.”
Fall Prevention: “strategy using specific interventions to avoid risks of falling.”
(Briggs National Quality Improvement/Hospitalization Reduction Study)
Factor Contributing To Patient’s Falls
History:History: Previous fall history.
Physical Status:Physical Status: Fatigue/weakness Dizziness/balance problem Impaired mobility Sensory impairment Seizures disorder Alteration in elimination
Mental Status:Mental Status:
Confused (illogical thinking) Impaired memory/judgment Disoriented to time place or person Lack of familiar with immediate
surrounding Inability to understand/follow instructions
Factor Contributing To Patient’s Falls cont...
Medications:Medications: Drugs that have diuretic effects Drugs that alter thought process
and or create hypotensive effects (narcotics and sedatives, psychotropic, hypnotic, tranquilizers, antihypertensive)
Drugs that increase GI motility (laxative, enemas, cathartics)
Factor Contributing To Patient’s Falls cont...
Other factorsOther factors Wet floor No orientation to unit Slippery floor Area under construction Less light/darkness Obstacles e.g. cords/wires in the way Transferring of patients from bed to
Stretcher/wheel chair Faulty equipments such as Mobility aids
Factor Contributing To Patient’s Falls cont...
Nurses Assessment
Nursing Specific Intervention Strict implementation of nursing initial falls
assessment and daily reassessment. Patients should be screened by assessing
intrinsic and extrinsic fall-related risk factors Orientation to unit Calling bell beside patient and in
the bath room Patient and family education
regarding medication effects and side effects Teach patient use of grab bars Bed side and trolley's rails up Beds at low level
Nursing Specific Intervention
Lock all equipment while transferring patients
Continues dryness of wet floor and putting warning signs during cleaning
Isolate the construction area Presence and maintenance of
emergency lights every where.
Post Fall Nursing ActionPost Fall Nursing Action Immediate call for help Assess for injuries Obtain and record
sitting/standing vital signs Assess for change in range of
motion Alert physician Follow organizational policies
for patient monitoring Assess intrinsic and extrinsic
factors for fall
But we need to share the learning fromour mistakes to try and stop them
happening again …..
So...So...
Document the circumstances in medical record
Complete incident report (HERF(health care event reporting form), Patient Safety Event Report: Fall)
International Patient Safety GoalsGoal 6 - Fall Risk Assessment
There is a policy regarding fall risk assessment and reassessment for all patients in the hospital, however the policy did not emphasized monitoring the unintended related consequences of the fall reduction measures.
Unintended Consequences Monitor patient for unintended related consequences
of the fall reduction measures i.e. limiting water intake, restraint related injuries and patients jumping over the bed side rail.
References References
http://www.ftmc.com/content.aspx?PID=231
http://www.nursingcenter.com/prodev/cearticleprint.asp?
www.ncvhs.hhs.gov/070619p8.pdf http://www.kevinmd.com/blog/2009/07/the-
unintended-consequences-of-preventing-patient-falls.html
THANKSSTAY BLESSED