Root Cause Analysis Essay Paper
Root Cause Analysis Essay Paper
Root-Cause Analysis
The issue of concern is avoidable fall incidences among patients in medical facilities. Avoidable falls are common in medical facilities, generally occurring at an approximate rate of 4.5 falls per 1,000 patient days. About 30% of these falls result in injury while 5% result in serious injury that could be fatal to include excessive bleeding, subdural hematomas, and fractures. In addition to threatening the health of patients, avoidable falls also increase the cost of health care. Patients who experience falls pay as much as $4,000 higher than their counterparts who do not fall, and also spend more time in the medical facilities as they recuperate. Besides that, patients who experience falls are likely to report mental harms such as loss of self-confidence, fear of falling, and anxiety (Graban, 2018). Owing to the risk of emotional harm, increased costs and significant injury associated with avoidable fall incidences in medical facilities, there is a need to implement strategies for preventing falls in medical settings as an important public health and patient safety concern. This can be best achieved by conducting a root-cause analysis to determine the cause of avoidable fall incidences before identifying strategies to address the causes (Hickey & Kritek, 2012). Along this line, the present paper conducts a root-cause analysis of avoidable fall incidences and presents a safety improvement plan intended to efficiently and effectively address the problem of avoidable fall incidences in medical settings.
Analysis of the Root Cause
Avoidable fall incidences within the medical facilities settings continued to be a serious concern with the most adverse events leading to increased health care costs, longer lengths of stay and injury among hospitalized patients. Root Cause Analysis Essay Paper The falls rates considerably vary by medical facility and unit type. However, there is a general consensus that they are a common problem. The first step in preventing falls is identifying the root cause of these events. In this regard, there is a notable correlation between some risk factors and fall incidence. These risk factors identify the patients who are more susceptible to falling and to who targeted intervention is anticipated to prevent falls (Williams, Malani & Wesorick, 2013).
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Although there is no definite explication of the risk factors, as there is no definitive consensus on the number and types of risk factors that lead to falls, it is imperative that these risk factors. That is because these risk factors have been previously targeted in other facilities but fall incidences have not been completely eliminated. The risk factors are of two main categories. The first category is intrinsic factors that include use of medication and chemical agents, imbalance, musculoskeletal disorders, gender and age. The second category is extrinsic factors that entail weaknesses inherent in the medical facility and system in terms of teamwork, training, communication, human resources, and medical equipment design and maintenance. The interactions between the extrinsic and intrinsic risk factors creates opportunities for falls incidences (Perry, Potter & Ostendorf, 2016).
The present analysis focuses on patient-related factors. It is determined that although patient falls have a multiple etiology, patient-related factors have been largely ignored. The identified factors include gender and age. Incidences of falls and fall related injuries are more common among females and older patients, likely the result of gender-based and age-based physical declines. Besides that, conditions such as visual impairment, urinary incontinence, heart disease, diabetes and arthritis are associated with age and they act as predictors for increased risk of falls among patients. To be more precise, aging in combination with gender and other factors such as confusion and poor mobility typically result in falls and subsequent injuries among patients. Another patient related factor is walking aids and balance difficulties. Additionally, poor vision is an issue of concern since it is associated with sensory loss, false perception of the environment, poor balance and reduced visual acuity. Also, frequent urination and incontinence is a concern with patients having to visit the toilets frequently on frequently cleaned floors that could be slippery (Vincent & Amalberti, 2016).
Improvement Plan with Evidence-Based and Best-Practice Strategies
The root cause was identified as patient related factors. Addressing these factors requires the facility to administer a standardized fall risk assessment tool at admission to collect information that helps with developing an individualized care plan. It asks key questions so that the typical risk factors are identified. This is important in helping medical personnel effectively identify patients at high risk of experiencing falls. In fact, the assessment tool is important for four reasons. Firstly, it facilitates communication between care settings and medical personnel through presenting a common language for describing risk. Secondly, it facilitates care planning through focus on specific dimensions that place the patient at greater risk of fall. Thirdly, it allows for targeted preventive interventions that makes good use of the available resources to achieve the most benefit. Finally, it aids in decision-making through ensuring that key factors are identified and acted upon. The key risk factors that form part of the assessment include continence, mental status, medication, mobility and use of assistive devices, history of falls, vision, and gait (Vincent & Amalberti, 2016).
In addition to the mentioned strategies, the facility should implement a universal fall precaution approaches that applies to all patients regardless of fall risk. These approaches focus on ensuring that the care environment is comfortable and safe. This includes following safe patient handling practices, cleaning spills promptly even as floor surfaces are kept clean and dry, having study handrails in patient areas, providing non-slip footwear, and familiarizing the patient with the unit environment (Williams, Malani & Wesorick, 2013). Applying the fall prevention approaches are important because they not only safeguard the patients but also medical personnel and visitors through maintaining a comfortable and safe environment. Failing to implement these approaches would not only place patients at risk of falls, but would also place medical personnel and visitors at risk of falls. These measures should be documented in rounding notes and carefully integrated into workflow to ensure that they are diligently implemented (Graban, 2018).
Existing Organizational Resources
There are existing organizational resources that will help improve the implementation of the plan. The first resource is the facility administration and top managers who determine facility policies and operating procedures. They are required to offer leadership support by approving the plan and supporting its implementation as a new facility policy. In addition, the help to remove implementation barriers across departments and authorize resources for use (Hickey & Kritek, 2012). The second resource is middle managers, medical personnel and support staff who are involved at the unit level. They are responsible for realizing the plan through actualizing its components such as administering the standardized fall risk assessment tool, ensuring patients wear non-slip footwear and ensuring that floors are dry. The third resource is the unit champions. They are responsible evaluating the performance of the plan and gathering feedback. The fourth resource is the implementation team that is responsible for evaluating data related to the plan’s performance to include tracking assessment changes and incidence rates before suggesting improvements (Hickey & Kritek, 2012).
References
Graban, M. (2018). Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement (3rd ed.). Boca Raton, FL: CRC Press.
Hickey, M., & Kritek, P. (2012). Change Leadership in Nursing: How Change Occurs in a Complex Hospital System. New York, NY: Springer Publishing Company, Inc.
Perry, A., Potter, P., & Ostendorf, W. (2016). Nursing Interventions & Clinical Skills (6th ed.). St. Louis, MO: Elsevier.
Vincent, C., & Amalberti, R. (2016). Safer Healthcare: Strategies for the Real World. New York, NY: Springer Publishing Company, Inc.
Williams, B., Malani, P., & Wesorick, D. (eds) (2013). Hospitalists’ Guide to the Care of Older Patients. Hoboken, NJ: John Wiley & Sons Inc. Root Cause Analysis Essay Paper
