Patient Safety: Identifying Fall Risks During Patient Transfer.

The electronic health record: An essential tool for advancing patient safety

Contemporary issues in nursing: patient safety, decision-making and social support in challenging economic times

Effective communication is an important element in professional nursing practice and a major element of patient safety goals because communication is the first cause of patient safety issues. The purpose of this study is to examine effective communication based on situation techniques, background techniques, assessment techniques and recommendation techniques for patient safety at Bhayangkara Kendari Hospital. Type of research with a cross-sectional approach. Data analysis was performed with SPSS statistical tests using univariate, bivariate and multivariate analysis. The sample in this study was 93 people, the sampling technique is a total sampling method.The results of this study showed that the situation technique had an insignificant influence on patient safety at Bhayangkara Kendari hospital with p values of 0.710 > 0.05. The background technique has an insignificant influence on patient safety at Bhayangkara Kendari hospital with p values of 0.234 > 0.05. The assessment technique has a significant influence on patient safety at Bhayangkara Kendari Hospital with p values of 0.003 < 0.05. The recommendation technique has a significant influence on patient safety at Bhayangkara Kendari hospital with p values of 0.031 < 0.05. For the nursing profession, the results of this research can improve the quality of service by sharing experiences. Future research will need to explore other factors that affect patient safety, such as infection prevention and fall risk, to support improved hospital care practices.

Patient safety encompasses a system of services designed to ensure that patients feel secure. This includes proper identification, learning from incidents, injury prevention due to errors, follow-up actions, risk analysis, patient incident assessment, and risk management related to reporting. Implementing solutions to minimize risks also involves preventing injuries caused by employee negligence in performing incorrect actions. The objective of this research is to determine the impact of nurses' knowledge, attitudes, and practices regarding patient safety on the risk of patient falls. The study design is quasi-experimental (Pre and Post Test Without Control). Data analysis utilized univariate and bivariate methods. In this study, 50 respondents participated in an intervention. The average pre-test and post-test scores were analyzed to evaluate the influence of nurses' knowledge, attitudes, and practices on patient safety concerning the incidence of fall risk. The results indicated that there was no significant influence of knowledge and application of patient safety on fall risk (p-Value 0.230 > 0.05). However, there was a significant influence of nurses' attitudes on fall risk events (p-Value 0.000 < 0.05).

Nurses represent a limited resource in the hospital environment. For decades, inpatient nurses have conducted head-to-toe assessments in roughly the same manner. At Mayo Clinic in Rochester, Minnesota, the practice has been twice-daily head-to-toe assessments, without reviewing the benefit of this frequency (vis-à-vis once daily) for patients, staff, and the institution. This quality improvement (QI) project in a general care setting explored whether decreasing comprehensive physical assessments from twice daily to once daily was associated with changes in patient safety or care quality. Staff satisfaction was also assessed. After a pilot project showed the feasibility of changing to once-daily assessments, a QI project was conducted to compare a once-daily frequency of head-to-toe assessments with a twice-daily frequency for all adult patients admitted to a general medical unit. The intervention period was between August 1 and October 31, 2023; one assessment was performed between 7 AM and 7 PM in all patients not receiving hospice care or requiring more frequent assessments because of specific disease processes. Comparison data were obtained from patients who were on the unit in the three months before the intervention, from May 1 through July 31, 2023. Outcomes were patient safety events, code blue events, and rapid response team calls; hospital length of stay; performance rates of other required assessments (as a counterbalance measure), including delirium, pressure injury, and fall risk; and compliance with the new assessment schedule. At the conclusion of the intervention period, no significant increases in reported patient safety events, code blue events, rapid response team calls, or hospital length of stay were observed. There were no decreases in compliance with required assessments, except for pressure injury, which decreased enough during the first month of the intervention to result in a statistically significant difference between the pre- and postintervention periods; however, compliance returned to baseline by the conclusion of the project. Among nursing staff, compliance with the once-daily assessment practice was high (80%), and staff feedback was positive; 96% of respondents indicated they would like to see the practice continue. The results of this QI project suggest that head-to-toe assessment frequency in the adult general medical patient population could be reduced to once daily without adversely affecting patient outcomes or safety. Further research is warranted to examine whether these results can be extrapolated to other units and institutions.

BACKGROUNDFall injuries among children during hospital stay is a major patient safety issue. Inpatient pediatric falls can lead to numerous negative consequences. In contrast to adults, there is a paucity of information on the prevalence and risk factors associated with children’s falls during hospitalization.OBJECTIVESIdentify the prevalence of fall injuries among hospitalized children and describe the demographic and environmental factors that could predict a higher risk of severe outcomes of fall.DESIGNDescriptive, cross-sectional prevalence study.SETTINGSpecialized children’s hospital.PATIENTS AND METHODSData was obtained through the electronic Safety Reporting System (SRS). All reported fall events during hospitalization in children ≤14 years of age for the period from 1 April 2015 to 30 April 2016 were included. Fall events that occurred in the day care unit and the outpatient clinic were excluded.MAIN OUTCOME MEASURESPrevalence and possible risk factors for fall events.SAMPLE SIZE48.RESULTSThe prevalence of falls among the 4860 admitted children was 9.9 (95% CI=7.5, 13.1) per 1000 patients (48/4860). A majority of the falls were among boys (n=26, 54%), in the age group from 1–5 years old (n=22, 46%), in children at high risk of falling (n=35, 73%), with normal mobility status (n=21, 44%), and with no history of previous falls (n=33, 69%). Severe injuries accounted for 25% of falls (n=12). However, falls among the moderate risk category (n=9, 69%) were more often severe than falls among the high risk category of children (n=12, 34%) (P=.03).CONCLUSIONRisk factor identification is required to prevent falls and their severe outcomes.LIMITATIONSUnderreporting and single-centered study.

Decades of research have been conducted on the risk, prevention, and management of falls. Extensive research addresses the identified intrinsic and extrinsic fall risks and the importance of screening for these risks. The emphasis for patient safety interventions surrounding falls and injury prevention must be on patient-centered, multifactorial, individualized care plans that are population-based. Yet the link between risk assessment and the effectiveness of population-based interventions remains weak. Early efforts focused on risk factors for prevention of falls in the elderly, largely ignoring interventions and also considering all fallers as one single group. Research then moved into fall screening and risk assessment, but these two processes were often intermingled, leading to confusion about linking risk to specific interventions. Still the focus was on fall prevention and the elderly, lumping all fallers into one single group. Next, research focused on interventions, but the focus was on fall prevention and the elderly, again lumping all fallers together. A new agenda begins to question this focus on fall prevention and addresses fall protection and injury prevention, emphasizing therapeutic risk associated with activity and community participation. This new agenda also recognizes the need to segment high-risk patient populations to identify unique risks and tailor interventions (e.g., peripheral neuropathy, wheelchair fallers) using new three-dimensional techniques to assess gait and balance as well as other key risk factors. The new agenda also goes beyond fall screening and fall risk assessment, emphasizing the need to screen individuals, follow up with in-depth risk assessment protocols, and link interventions to specific modifiable risk factors. As more evidence is available to clinicians, for translational research efforts are needed to develop clinical tools to make it easier for clinicians to provide evidence-based practice and to explore more effective and efficient strategies for implementing evidence-based programs across clinical settings and facilities. To advocate for evidence-based practice in fall prevention and fall protection, the Veterans Integrated Service Network (VISN) 8 Patient Safety Center of Inquiry held its second international call across professions and experts to articulate the state of the science, elucidate research priorities, and facilitate the translation of research into practice. In April 2007, fall experts from the United States and Canada participated in a three-day national conference, Transforming Fall Prevention Practices. After presenting state-of-the-art knowledge and practices in fall prevention, risk assessment, and interventions, they joined with invited research methodologists and expert clinicians over another half day for the research agenda-setting session. Participants reached consensus on the research needed to advance both science and clinical practice. Priorities were grouped into three research domains: * Clinical interventions. * Biomechanics. * Implementation/translation. The criteria used for selecting research priorities were the-- * Need for consensus among all members. * Feasibility of the research being conducted within 5 years. * Presence of an existing program of research on which to build. * Fit with the mission and vision of the Veterans Health Administration (VHA) in primary health promotion, patient safety, function, and independence. This editorial focuses solely on clinical intervention. We examined the current state of the science relevant to clinical intervention research and developed a research agenda for studies that can be conducted as 5-year research programs likely to result in new discoveries, improved clinical practice, reduced variations in practice, and improved patient outcomes. Clinical intervention research is needed to test the effects of specific interventions related to special populations, medication prescribing, clinical units and staffing, and interdisciplinary approaches to fall prevention [1]. …

One of the goals of patient safety is to prevent patient falls. Patient falls are an incident in hospitals that result in injury and even death of patients and are the second most common adverse event in health services after medication errors. Nurses can prevent falls by implementing fall prevention guidelines such as closely monitoring patients at high risk of falling and involving the patient's family to avoid falls. Nurses have a role in assessing and managing falls in patients by providing education to patients and taking fall prevention measures based on applicable Standard Operating Procedures. This case study aims to determine the assessment and management of fall risk in the Aceh Government Hospital inpatient ward. The sampling technique used total sampling with a total of 23 nurses. Data was collected in September 2023 after obtaining institutional permission and filling out informed consent to become a research respondent. The data collection tool uses an observation sheet to assess and manage fall risk, developed based on Standard Operational Procedures. Data analysis uses descriptive statistical tests. This case study shows that 78.2% of nurses did not carry out fall risk assessments, and 74.00% did not manage fall risks. As direct superiors of nurses, first-line managers can carry out supervision, guidance, and regular discussions to assess and manage fall risk. Hospital Patient Safety Committees must provide ongoing training regarding patient safety goals to improve patient safety.

Introduction Frailty presents significant challenges to healthcare systems, particularly in Thurrock, Essex, where 14% of residents are aged 65 or older. This demographic shift, combined with socioeconomic factors, underscores the need for patient-centred, clinically effective, and tailored healthcare services that prioritise patient safety. Aim To improve frailty management for elderly patients in Thurrock by integrating pharmacist support within a nurse-led service, focusing on medication management, reducing workload pressures, providing holistic, patient-centred care, and ensuring patient safety to enhance outcomes and reduce hospital admissions. Method A 12-week pilot involved patients aged 65+ undergoing joint reviews with a frailty nurse and pharmacist. Participants had a Rockwood Frailty Score of 5–7 and at least one long-term condition. Reviews included evaluations of medication, functional and falls risks, nutritional status, fracture risk, and blood tests. The management phase focused on deprescribing, dose adjustments, and addressing health metrics such as postural hypotension, bone protection, and falls risk. Regular follow-ups ensured coordinated care with a focus on patient-centred outcomes and patient safety. Results From April 4 to June 28, 2024, 37 patients (mean age: 84) participated. Comprehensive assessments led to 155 interventions (averaging 4.07 per patient). Medication management improved significantly, with 88 drugs deprescribed, including 55 Falls Risk Increasing Drgs (FRIDs), resulting in a 14.39% reduction in FRIDs and a 23.03% reduction in polypharmacy. These interventions led to £6252.18 in annual drug savings and a 974.09 kg reduction in CO2 emissions. Key outcomes included 57 health and social interventions. Financial analysis suggested savings of £63,450 from preventable hospital admissions, with a return on investment (ROI) of 1655.4%. Conclusion The pilot demonstrated the clinical effectiveness of pharmacist-nurse collaboration in improving medication management, chronic condition control, reducing falls risk, and preventing hospital admissions. It emphasises the importance of patient-centred care, safety, and skill mixing to enhance clinical outcomes.

Bu çalışmanın amacı bir cerrahi serviste çalışan hemşirelerin hasta güvenliğine ilişkin deneyimlerini belirlemektir. Nitel araştırma desenlerinden fenomenolojik yaklaşımla verileri toplanan bu çalışma bir eğitim ve araştırma hastanesinin genel cerrahi servisinde çalışan 9 hemşirenin katılımıyla Ocak-Şubat 2020 tarihleri arasında gerçekleştirilmiştir. Çalışma öncesinde etik kurul ve kurum izinleri alınmıştır. Veri toplamada “Tanıtıcı Bilgi Formu” ve yarı yapılandırılmış “Görüşme Formu” kullanılmıştır. Analizler, Giorgi’nin fenomenolojik yöntem analizi kullanılarak yapılmıştır. Araştırmadan elde edilen veriler 5 ana ve 6 alt temadan oluşmaktadır. Ana tema ve alt temalar; 1. Hasta Güvenliği Nedir?, 2. Cerrahi Süreçte Hasta Güvenliği (Ameliyat Öncesi Süreçte Hasta Güvenliği ve Ameliyat Sonrası Süreçte Hasta Güvenliği), 3. Hasta Güvenliği ve Sorunlar (Sorun Sırasında Sorumlu Kişi ve Sorunlu Konular ve Önlemler), 4. Hasta Güvenliği ve Hemşirelik Uygulamaları (Güvenli Cerrahi Kontrol Listesi Kullanımı ve Uygulamalara Yönelik Öneriler) ve 5. Deneyimler’dir. Katılımcılar, perioperatif süreçte hastalarda özellikle banyo ve tuvalette düşmelerin çok yaşandığını, yanlış ilaç uygulamalarının ve sıvı transfüzyonlarının sıkça yapıldığını bildirmişlerdir. Bu durumların önlenmesi için; hasta başlarına 4 yapraklı yonca asıldığı, yatak kenarlıklarının kaldırıldığı, İtaki Düşme Riski Ölçeği’nin doldurulduğu, hasta güvenliğini tehdit edecek durumlarla ilgili hastaya ve yakınlarına bilgi verildiği ifade edilmiştir. Cerrahi birimlerdeki hemşirelerin, hasta güvenliğine ilişkin hemşirelik girişimlerini ve bu girişimlerin yasal yönlerini bilmeleri konularında gerekli eğitimleri almaları önerilebilir.

Information exchange in oncological inpatient care – Patient satisfaction, participation, and safety

The prevention of errors and negative consequences on patients associated with health care is referred to as patient safety. Healthcare has become more complex as new technologies, drugs, and treatments have become more widely available. Every year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), resulting in 2.6 million deaths worldwide. Many medical practices and healthcare risks are emerging as critical issues for patient safety, significantly increasing the burden of harm caused by unsafe care. There are numerous predictors, including safety and risk management, medication errors, fall risks, unsafe surgical care procedures, diagnostic errors, hospital-acquired infections, and diagnostic errors, all of which pose a risk to patient safety measures. The role of a nurse surrounds the complete analysis of the solemn issue associated with the well-being and safety culture. Nurses contribute to patient safety by remaining at patients' bedsides and interacting with their families and other healthcare professionals.

Falls are common during hospitalization and associated with adverse outcomes including fractures, head injury, and even death. In the past decade, fall prevention has become a significant patient safety concern. In 2005, the Joint Commission included fall prevention as a National Patient Safety Goal and in 2008 the Centers for Medicare and Medicaid Services (CMS) identified falls with injury as a “never” event. Numerous fall risk assessment tools have been developed; however, few have been validated in more than one population. Single and multicomponent interventions have been tested in an effort to identify methods to reduce falls during hospitalization. However, the data regarding successful hospital fall prevention programs are sparse. The majority of these programs utilize bedside interventions such as frequent rounding, bed alarms, or low beds. While some of the individual studies have been successful, systematic reviews and meta-analysis have been less positive. One potential problem may be these interventions are not enough to reduce falls when tested in hospital systems that do not provide a culture of patient safety. Addressing larger system-wide concerns like improving handoffs and communication or improving knowledge and skills related to fall risk and prevention may be the key to reducing hospital falls. Root cause analysis (RCA) has been used extensively in hospitals to address falls in a systematic fashion with a goal of identifying and correcting the root cause to reduce reoccurrence. However, for patient safety problems like falls, that are high-volume and high-risk, aggregate RCA may be more appropriate. The aggregate RCA tool supports process and systems improvement by identifying trends and system issues across groupings of similar events. In the future, fall prevention strategies will need to address these system issues in order to be successful.KeywordsNursing StaffFall PreventionFall RateMultifactorial InterventionRoot Cause AnalysisThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Background and Purpose: One of OhioHealth’s strategic priorities includes improving patient safety by eliminating preventable patient harm. The Integrated Stroke Unit (ISU) at Riverside Methodist Hospital worked to achieve this goal by reducing falls by 20%. The ISU consistently experienced a higher fall rate compared to like units across the nation. The ISU averaged over 7 falls per month with injury falls steadily increasing. The ISU experienced inconsistencies related to fall risk assessment and fall prevention interventions. As a result, a Fall Risk Scorecard was created to streamline interdisciplinary team work, increase patient safety, and improve safe patient handling and mobility. Methods: A multidisciplinary approach was used to improve patient safety and determine the root cause for patient falls. A team of nurses, rehab therapist, and patient support assistants was established. Inconsistencies were identified related to recognition of patients at risk for falls, types of fall interventions in place, and bed alarm knowledge and utilization. A need for visual management to standardize practice was seen. A Fall Risk Scorecard was created to help identify fall risk patients, standardize fall prevention interventions, and provide knowledge to staff regarding the patient’s activity level. The PDSA cycle was used to create standard work for the care team. Educational materials were developed and one-on-one training was provided to staff. The multidisciplinary approach helped to create a standardized process for each therapist coming to the ISU. The Fall Risk Scorecard was piloted for 3 months. Results: During the pilot, the unit saw a 57% reduction in falls. Current state, the ISU has continued to utilize the Fall Risk Scorecards and has sustained a 57% reduction in falls. With the utilization of lean methodology, members of the care team were able to ensure the right patient received the right intervention at the right time. With these results, the pilot has been selected for a system-wide roll-out over 11 different care sites. Conclusion: By taking a collaborative approach, utilizing lean methodology, and real-time problem solving, the ISU has successfully reached their goal to increase patient safety and improve safe patient handling and mobility.

Objective: Fall is one of the major risks among different categories of patients including patient with neurological disorder who is at high risk of falling, which increasing their level of dependency. Nurses’ roles in identifying the falling risk and barriers of patient safety became a vital need in order to alleviate those risks and improving patients' safety and to minimize this adverse event. Aims of the study are to: identify nurse's assessment of falling risk and barriers of patient safety measures among patients with neurological disorders. Research questions: can nurses identify falling risk among neurological patients with different conditions? Does nurses aware about the barriers of applying universal precautions and patients safety in different conditions? What are the interventions methods to overcome these barriers? Research design: A descriptive cross sectional research design was used. Setting: The study was conducted at center of psychiatric medicine and brain and neurology disease, Tanta University. Subjects: finite sample including, all nurses work in ICU and brain and neurology units (46 nurses out of 50) nurses. Tool: Two tools were used for data collection. Tool one Nurses assessment of the factors affecting patient condition, tool two Prevention of to assess. Results: there was a significant difference regarding insisting of patient to move as barriers of patient's safety. Conclusion: the present study finding concluded that: Lack of nurses’ knowledge and practice in applying risk assessment of fall and universal precautions due to number of barriers including inadequate facilities and negligence of hospital management. Recommendations: application prevention of falling program by hospital management, and establish interdisciplinary team for training programs for staff nurses.