Quality Benchmark Assignment
Manuel Giovanni Garnique
Denver College of Nursing
NUR 415 – Policy, Finance, and Quality in Nursing and Healthcare
Quality Benchmark Assignment
Patient falls are a significant concern in the healthcare industry, posing risks to patient safety and causing physical injuries, extended hospital stays, and increased healthcare expenses. Factors like alarm fatigue and shorter hospital stays contribute to the problem. The recognition of complexities surrounding patient falls and the implementation of suitable strategies help in the mitigation of the occurrence (Wong et al., 2022).
Background and Information
Addressing patient falls and implementing preventive measures are crucial for improving care quality and complexities. Healthcare organizations can create a safer environment, reduce the burden on the system, and promote optimal patient outcomes by prioritizing interventions to prevent falls. Prioritizing these efforts is essential for safeguarding patient well-being and enhancing healthcare delivery quality.
Patient falls are a growing concern in healthcare facilities due to their impact on patient outcomes and their financial burden on the healthcare system. Falls are the leading cause of injury among hospitalized patients, affecting approximately one million people in the United States annually, according to the Agency for Healthcare Research and Quality (Agency for Healthcare Research and Quality, n.d). Falls can cause minor bruises to more severe injuries such as fractures or head trauma, resulting in more extended hospital stays, higher healthcare costs, and lower patient satisfaction.
Previous Attempt to Address Patient’s Falls
Alarm fatigue is a significant factor in patient falls in healthcare facilities. Frequent alarm activation can cause desensitization and decreased response rates among healthcare providers, leading to delayed or overlooked alarm signals. This compromises patient safety by allowing alarms related to bed exits or movement to go unnoticed. Shorter hospital stays can be cost-saving but pose challenges to patient safety (Wong et al., 2022). Patients may be discharged before fully recovering or at risk of falling, increasing the likelihood of falls outside the hospital setting. This raises the question of who bears the responsibility and cost if a patient falls after being discharged from the hospital.
Fall prevention programs have been developed to address the critical issue of patient falls and improve patient safety. These programs include comprehensive risk assessments, environmental modifications, patient and family education, and staff training. The systematic identification and assessment of patients’ fall risks are crucial, as it helps healthcare providers tailor interventions and strategies to address specific patient needs (Agency for Healthcare Research and Quality, n.d). Environmental modifications, such as well-maintained surroundings, adequate lighting, and assistive devices, prevent falls. Patient and family education is integral to fall prevention programs, empowering patients and their families to participate in their care actively.
Education may include teaching patients how to use assistive devices correctly, promoting regular exercise and physical activity, and raising awareness about calling for assistance when needed. Staff training and education are essential to successfully implement fall prevention programs. Healthcare professionals must be educated about fall risk factors, prevention strategies, and proper protocols for assessing and responding to at-risk patients (Agency for Healthcare Research and Quality, n.d). Ongoing training programs and updates are necessary to inform healthcare providers about evidence-based practices and ensure a consistent approach to fall prevention across the organization.
Stakeholders and their Roles Addressing the Issues
The collaboration of various stakeholders within the healthcare system is required to resolve the patient effectively falls issue. These stakeholders are critical in identifying, implementing, and maintaining interventions to reduce patient falls and improve patient safety. One of the stakeholders is the healthcare providers and other staff members. Health providers such as physicians, nurses, and other healthcare providers and staff play a direct role in patient care and safety (Buljac-Samardzic et al., 2020). They are in charge of identifying patients at risk of falling, implementing preventive measures, and responding quickly to alarms and patient needs. Proper training and education are essential for healthcare providers to address patient falls effectively.
Patients and their families are also stakeholders. Patients and their families take an active role in fall prevention. They must be educated about fall hazards, encouraged to use recommended safety precautions, and given the ability to express their concerns (Heng et al., 2022). Patients and families help fall prevention programs succeed by following guidelines and reporting changes in patient conditions.
The other stakeholders are the hospital administration and leadership. The hospital administrators and leaders allocate resources, establish policies, and foster a patient-safety culture. Their assistance is critical for implementing comprehensive fall prevention programs, providing necessary training, and fostering an environment that prioritizes patient safety (Heng et al., 2022). The quality improvement teams also play a crucial role in addressing this quality issue. These groups are made up of professionals who are dedicated to improving patient care and safety. They analyze data, identify trends, and implement evidence-based practices to reduce patient falls. Quality improvement teams work with other stakeholders to develop and refine fall prevention strategies.
The other key stakeholder is the regulatory Agencies. Government and healthcare regulatory agencies like the Joint Commission establish patient safety guidelines and standards. Their participation ensures that healthcare facilities follow best practices and regulations regarding fall prevention.
Power Bases and the Influence
Healthcare power structures are critical in influencing the implementation of fall prevention strategies. Healthcare professionals knowledgeable about patient safety and fall prevention can influence their colleagues by sharing their knowledge, best practices, and evidence-based interventions. Administrators and leaders in hospitals have the legal authority to enforce policies, allocate resources, and drive change initiatives. Respected and influential healthcare community members can advocate for fall prevention and inspire others to join the fight (Turner et al., 2020). For example, access to data, research, and patient outcomes can influence decision-making and drive commitment to change. Healthcare professionals can effectively implement fall prevention strategies and improve patient safety by understanding and leveraging these power bases.
Resources Required for the Implementation of the Change
Implementing effective patient fall prevention strategies necessitates a wide range of financial, human, and technological resources. Financial resources are critical for promoting the development and implementation of effective fall prevention programs. This includes funding for critical components such as staff training, installing alarm systems, providing assistive devices, implementing environmental improvements, and deploying data collection and analysis tools (LeLaurin & Shorr, 2019). Human resources, which include skilled healthcare professionals such as nurses, physicians, and quality improvement experts, are critical. Their knowledge is essential for identifying at-risk patients, conducting thorough risk assessments, and implementing preventive measures. Ensuring optimal staffing levels, as well as well-structured training programs, becomes critical to success.
Simultaneously, technological resources have a significant impact. Advanced alarm systems, patient monitoring technology, electronic health records, and practical communication tools contribute significantly to the rapid response and prevention of fall incidents. Incorporating technology improves the accuracy and efficiency of fall risk assessments and subsequent interventions. Furthermore, the distribution of educational resources remains critical (Sutton & Pincock, 2020). Comprehensive educational materials and training modules are critical tools for educating healthcare providers, patients, and families about potential fall hazards, effective prevention strategies, and appropriate response protocols.
The formation of collaborative networks improves the efficacy of fall prevention initiatives. Collaboration with external organizations, research institutions, and regulatory agencies provides access to best practices, invaluable research findings, and relevant guidance. This collaboration broadens the scope of fall prevention strategies, increasing their effectiveness and impact (Severance et al., 2022). The coordinated use of these disparate resources lays the groundwork for a comprehensive and multifaceted approach to addressing the critical issue of patient falls in healthcare settings.
Agency for Healthcare Research and Quality. (n.d). Falls. Retrieved from
Buljac-Samardzic, M., Doekhie, K. D., & van Wijngaarden, J. D. H. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade.
Human Resources for Health,
Heng, H., Kiegaldie, D., Slade, S. C., Jazayeri, D., Shaw, L., Knight, M., Jones, C., Hill, A.-M., & Morris, M. E. (2022). Healthcare professional perspectives on barriers and enablers to falls prevention education: A qualitative study.
17(4), e0266797. https://doi.org/10.1371/journal.pone.0266797
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing Falls in Hospitalized Patients.
Clinics in Geriatric Medicine,
35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007
Severance, J. J., Rivera, S., Cho, J., Hartos, J., Khan, A., & Knebl, J. (2022). A Collaborative Implementation Strategy to Increase Falls Prevention Training Using the Age-Friendly Health Systems Approach.
International Journal of Environmental Research and Public Health,
Sutton, R., & Pincock, D. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success.
NPJ Digital Medicine,
Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2020). Fall Prevention Practices and Implementation Strategies.
Journal of Patient Safety,
Wong, Y. G., Hang, J. A., Francis-Coad, J., & Hill, A. M. (2022). Using comprehensive geriatric assessment for older adults undertaking a facility-based transition care program to evaluate functional outcomes: a feasibility study.
22(1), 598. doi: 10.1186/s12877-022-03255-5