Adverse Event or Near Miss Analysis: Evaluating Quality Improvement and Patient Safety in Healthcare

While near misses and adverse events share the same spectrum regarding failure reasons, they are differentiated by the extra information they give on recovery variables and their substantially greater occurrence frequency. Enhancing patient safety mainly involves determining and fixing the problems in the system that may result in harm. This paper aims to examine an adverse or potentially harmful circumstance that occurred during my professional nursing experience. The report will assess quality improvement techniques connected to the incident, including relevant metrics, and design a quality improvement program to avoid a repeat adverse event. Additionally, the report will review the missing steps and the event’s ramifications.

Analysis of the sequence of events missed steps or protocol deviations

When I worked in a nursing home, I saw that falls were one of the most common forms of injury. About 1.6% of all residents in nursing homes have an injury due to a fall each year, according to the Agency for Healthcare Research and Quality (AHRQ, 2019). The hospital had recently admitted a new patient. In any case, after around four hours, the resident suffered their first fall while getting off the toilet. Their legs and arm were hurt in the mishap. Instead of being caused by the patient’s underlying condition, the event resulted from medical malpractice that neglected to take into account numerous crucial steps. The event was caused by disregard for protocol and the absence of a fall risk assessment. Subsequently, the hospital implemented a fall risk assessment tool to determine how likely patients were to have falls. Park (2018) argues that methods for assessing the risk of falls have predictive potential that might be useful in reducing the frequency of adverse events for patients. While this occurrence might have been prevented, further details, including why the examination was skipped, would improve this research. Thus, following the numerous established processes and suggestions, nursing homes may reduce patient falls and improve patient safety.

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Analysis of the implications of patient falls for all stakeholders.

This disturbing episode included numerous parties, including the patient, nurses, the nursing home administrator, and the patient’s family. The patient’s results will be awful in the short term because of the fall. The patient’s ability to carry out everyday tasks may be negatively affected for the foreseeable future due to the fall. Second, there are consequences, such as the necessity for nurses to take steps to reduce the number of patient falls. According to studies conducted by Montejano-Lozoya et al., nurses significantly influence both avoiding and reacting to patient falls (2020). Collaborating with nurses and other medical professionals is essential for fall prevention initiatives. A nurse may coordinate with other direct care professionals to detect patients at risk of falling and take appropriate action to safeguard them.

Because of this tragedy, the institution has earned the mistrust of the community at large. Montejano-Lozoya et al. (2021) state that patient falls result in increased healthcare costs and patient discontent. As a result of the tragedy, the facility made changes, such as educating staff on the warning signals of potential falls. There have been fewer injuries from falls because of this method’s widespread use. Lastly, the family’s out-of-pocket costs for their loved one’s care would increase due to the accident and the injuries sustained. These inferences are grounded on the concept that a collaborative effort is necessary to minimize resident falls in nursing homes. Given these findings, it seems reasonable to implement a program to reduce the risk of falls.

Quality improvement actions and technologies to reduce patient falls and increase their safety

Technology such as wearables, environmental sensors, and video networks might be utilized to track the frequency of falls. Accelerometers and gyroscopes are examples of the technologies used in wearable sensors. Gait analysis and mobility monitoring are two areas where this technology has found use. These sensors can predict falls in high-risk people. The risk of falls may be predicted with more precision when these sensors are used simultaneously, as stated by Rajagopalan et al. (2017). Accelerometers and pressure-sensing insoles are two examples of devices utilized in multi-sensor gait analyses. Therefore, such devices may accurately predict whether or not an elderly patient will have a fall.

Environmental sensors are also often used to monitor the setting and prevent any slips or fall from occurring. Patients’ daily activities at home or a medical facility may be monitored using this system’s several cameras. These cameras ensure that every feasible factor in slips and falls is considered and addressed. These technologies have their benefits but pose dangers, such as privacy breaches. Individuals not inside the cameras’ field of vision will not be captured (Rajagopalan et al., 2017). Long-term, these methods might assist in protecting nursing home patients from mistreatment by making it possible to keep a closer eye on every single one of them.

Data metrics

Information gathered from the facilities dashboard indicates a need for increased focus on quality control measures. The hospital has had 21 patient falls in the previous year. Fifteen falls caused no injuries, four caused moderate injuries, and two caused serious ones. Two locals were seriously hurt, including cuts and scrapes on their hands and knees. Patients had a 39.8% higher risk of suffering a skin rip, avulsion, hematoma, or substantial bruising after experiencing a fall (Falls dashboard 2022). According to these measures, most patient falls within nursing homes may be avoided. Two incidents in which the patient suffered serious injuries may have been avoided with proper fall risk assessment. These occurrences have all taken place within individual rooms occupied by residents. AHRQ reports that general care settings account for 57.5% of all patient falls (Falls dashboard 2022). These numbers show that the hospital has to undergo reform to ensure its patients’ safety.

AHRQ data suggests that in 2022, no injury was caused by 55.2% of all reported falls. Mild injuries occurred in 26.6% of the falls, while serious injuries occurred in 0.4%. As tragic as it is, 0.1% (208) of these incidents resulted in patient death (Falls dashboard 2022). The CDC’s findings also highlight the substantial health impact of patient falls. Evidence shows that one in four persons over 65 will fall each year. Medicare spends $31 billion yearly to treat people who have fallen. Indeed, among the elderly population in the United States, falls are the leading cause of injury and death (Take a Stand on Falls 2017). Fall-related damages and healthcare expenditures may be mitigated if this issue is resolved.

Quality improvement initiative to prevent patient falls

To lower the risk of falls among all hospitalized patients, the hospital may use universal fall prevention. A treatment plan should be developed based on the patient’s fall risk assessment results to address the patient’s unique risks and requirements and the standard fall prevention measures. Some examples include letting the patient become used to the space, keeping the patient’s belongings within easy reach, ensuring the floors are clean and dry and using proper procedures while treating the patient.

Individualized treatments and standard fall prevention measures are necessary for patients at increased risk for falls. Therefore, the hospital could tailor their treatment to the individual patient based on their risk factors. Patients who suddenly have an altered mental condition should be evaluated for delirium and given appropriate care. Patients who have trouble walking or moving about need support from hospital staff. Every person needing a cane, walker, or other mobility aid should have one, in excellent working condition, by their bedside. The risk for injury in those who have a history of frequent falls should also be evaluated by looking for factors such as osteoporosis and the use of aspirin and anticoagulants.

Administrative backing is needed to make fall prevention a facility-wide focus and stated objective. There should also be a substantial fall committee in place at the site. Employees who serve on the autumn committee may be eligible for rewards from their superiors. Employees should be updated about the changes between the present and planned methods of lowering the risk of falls. At least once a quarter, it is recommended that in-service training be held for employees and that educational reminders be posted. Also, the new employees should get training on assessment tools and the consequences of measures employed to minimize fall risk, the most important of which is incorporating resident input into a person’s care plan.

Conclusion

         It has been shown beyond a reasonable doubt that patient falls significantly impact nursing home residents. These unfavorable occurrences lead to injuries, which in turn leads to poor consequences and, more critically, expenses associated with healthcare. Nevertheless, nursing homes have access to various tools to combat the issue, including those provided by organizations such as the AHRQ and the CDC. As a result, the institution needs to consider launching a quality improvement project to solve this issue.

References

AHRQ. (2019, September 7). Falls. Patient Safety Network. Retrieved December 3, 2022, from https://psnet.ahrq.gov/primer/falls

Centers for Disease Control and Prevention. (2017). Take a Stand on Falls. Centers for Disease Control and Prevention. Retrieved December 3, 2022, from https://www.cdc.gov/features/older-adult-falls/index.html

Falls dashboard. AHRQ. (2022, September). Retrieved December 3, 2022, from https://www.ahrq.gov/npsd/data/dashboard/falls.html

Park, S. H. (2018). Tools for assessing fall risk in the elderly: a systematic review and meta-analysis. Aging clinical and experimental research, 30(1), 1-16.

Rajagopalan, R., Litvan, I., & Jung, T. P. (2017). Fall prediction and prevention systems: recent trends, challenges, and future research directions. Sensors, 17(11), 2509.