Category: NURS-FPX6016

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal Name Capella university NURS-FPX 6016 Quality Improvement of Interprofessional Care Prof. Name Date Data Analysis and Quality Improvement Initiative Proposal Good morning, everybody. I am ………… Today, we are going to analyze the critical concern of patient falls at Springfield General Hospital in detail; specifically, we will look into adverse events such as John’s fall, which unveiled areas for lapses in communication, failure to follow set safety protocols, and monitoring of patients. Statistics show that these accidents result in avoidable harm, decreased patient satisfaction, and increased hospital readmission. Thus, our quality improvement initiative has drawn on the PDSA framework to identify these challenges and address them through enhanced fall-risk assessments, training for staff members, and appropriate use of certain technologies such as bed alarms and EHR alerts. We can and will create safer environments supportive of both the patients and staff while significantly reducing the rates of falls. Analysis of Health Care Issues Data reveals that the patient falls issue in Springfield General Hospital is a persistent health concern: it reveals fall rates within the healthcare facility exceed the set national benchmark standards. Though the national benchmark for fall rates reported was 3.44 falls per 1,000 patient bed days (Venema et al., 2019), the health facility reported 6.2 fall rates in 2021, 6.4 in 2022, and 6.7 in 2023. These indicate an exceptional deviation from the expected performance. Moreover, patient satisfaction scores decreased from 85% in 2021 to 70% in 2023, suggesting that safety concerns could be related to the perceived quality of care by the patients. Also, the average hospital stay length increased from 4.2 days in 2021 to 5.1 days in 2023, indicating possible fall-related injuries complications. The quality of the data is reliable, as it derives from hospital performance records and validated reporting systems. Nevertheless, additional insights are required to identify cause-and-effect factors. Relying on a greater measure of quantification will limit understanding without complementary qualitative data, such as interviews with staff, feedback from patients, or direct observational audits. Such inclusions may contribute to a more holistic assessment of the causes and opportunities for improvement. Metric 2021  2022 2023 National Benchmark Fall Rate (per 1000 bed days 6.2 6.4 6.7  3.44 Patient Satisfaction (%) 85 % 78 % 70 %  – Average Hospital Stay 4.2  4.6 5.1 – Recommendations for Quality Improvement General Hospital will standardize using the Morse Fall Scale (MFS) for fall-risk assessments in all patient units. This standardized tool helps a health care professional to assess the risk of falls in patients based upon a set of criteria that includes having had falls in the past, mobility problems, and mental status. The hospital seeks to enhance the identification of fall risks in patients. At the same time, interventions are promptly conducted to help prevent falls by encouraging its utilization through general training of its staff and frequent assessments (Baumann et al., 2022). Springfield General Hospital should ensure a better understanding of what has been achieved in fall prevention by undertaking patient satisfaction surveys on fall prevention and safety measures. These surveys will collect important feedback from patients regarding their perception of the hospital’s fall prevention policies, the effectiveness of personnel communication, and overall safety and security. This will allow for better refining of the strategy, keeping in view the patient’s perspectives while implementing fall prevention strategies in the future (Dykes et al., 2020). Quality Improvement Initiative Proposal The fall-prevention quality improvement initiative at Springfield General Hospital will be conducted during a designed PDSA cycle toward continuous improvement. During the Plan phase, the hospital will standardize MFS to assess the fall risk for all patient units. This scale will rate how likely a patient is to experience an unintentional fall due to factors like a history of falls, mobility problems, and mental status. In addition, the hospital will emphasize training staff members on the consistent use of MFS. The hospital will also frequently assess which patients are at risk and ensure prompt interventions (Baumann et al., 2022). Patient satisfaction surveys will be proposed to collect feedback on fall prevention and safety measures; this would give insight into whether a productive fall-reduction protocol is in place from the patient’s point of view. This will refine the approach of the hospital and ensure that strategies match the needs and expectations of the patients (Dykes et al., 2020).In the Doing phase, Springfield General Hospital will engage in training staff to ensure that fall risks are identified using the Morse Fall Scale in a consistent and effective manner. The patient satisfaction survey will be administered to assess the extent to which the hospital’s fall prevention measures are perceived and how they affect overall safety and care satisfaction. NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal A post-fall review system will be used to assess missed intervention opportunities and to refine protocols. During the Study phase, the hospital will analyze data from the fall rate, survey feedback, and fall review outcomes to assess the impact of these interventions. All changes in protocol will be made based on this data. Findings from the surveys and continuing assessments will drive improvements and adjustments that will help improve patient safety and reduce fall rates over time.The fall-prevention quality improvement initiative at Springfield General Hospital identifies several key knowledge gaps and areas of uncertainty. First, there is limited understanding of the specific causes behind patient falls, particularly about patient demographics such as age, comorbidities, and medication use. More detailed data on these factors could refine risk assessments and prevention strategies. Second, while the Morse Fall Scale (MFS) will be standardized for use across all patient units, it is unclear how consistently and effectively it is currently utilized by staff. A closer examination of staff adherence to the MFS and any barriers to its use would provide valuable insights for improving its implementation. Finally, while patient satisfaction surveys will offer feedback on fall prevention, further qualitative research, such

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation Name Capella university NURS-FPX 6016 Quality Improvement of Interprofessional Care Prof. Name Date Quality Improvement Initiative Evaluation Springer General Hospital implemented a QI activity for Mr. John after the adverse event of his fall. Patient falls are an important safety concern in hospitals, and falls are reportedly one of the leading causes of injury, prolonged hospital stays, and increased mortality. According to Feng et al. (2022), hospitals globally experience approximately 134 million adverse events annually, leading to 2.6 million deaths, many of which are preventable falls. At Springfield General Hospital, QI initiative focuses on reducing fall-related incidents by adopting evidence-based, ready-to-implement fall prevention protocols such as frequent assessment of risk for falls, staff training, interdisciplinary communication, and combining the use of technology such as bed alarms and Electronic Health Records (EHR) alerts for at-risk patients.The incident involved Mr. John, who reported dizziness but was not reassessed for his fall risk. NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation A delayed response to his call light led him to try to walk unassisted and consequently fall, which could have been prevented had better communication, more improved adherence to fall prevention protocols, and timely interventions occurred. In the QI program at Springfield General, falls will be evaluated and mitigated using validated tools, such as the Morse Fall Scale. However, staff members will have to receive ongoing training on preventing falls by nurses and physical therapists, while technology-as in bed alarms and alerts from real-time EHR -will be incorporated to facilitate the early recognition of patients at risk of falls. However, one of the drawbacks highlighted in this program is the risk of staff alarm fatigue, which can lower the impact of these technologies. Moreover, the hospital was unable to distinctly ascertain the impact of these measures on all areas as different units were not using the new tools introduced to minimize falls in their entirety. These gaps in implementation and overcoming resistance to reporting adverse events for reasons of fear of job security will determine the success of this initiative. With these adjustments, the QI initiative at Springfield General Hospital shall make important cuts in fall-related incidents, improve patient safety, and secure a better environment of care for patients and healthcare providers. Evaluation of the Success of the Quality Improvement Initiative The QI initiative was assessed utilizing national benchmarks and outcome measures, such as a fall rate of 3.44 falls per 1,000 patient bed days, with this being one of the benchmark standards set for fall prevention performance (Venema et al., 2019). By comparing its fall rate to this benchmark, Springfield General can determine how effective its fall-prevention protocols are. Other interventions include the application of the Morse Fall Scale as a tool for assessing the individual’s fall risk, staff education and compliance rates, and the support of technology such as bed alarms and Electronic Health Record (EHR) alerts. These help monitor progress and ensure compliance with safety protocols. Such successful elements of this initiative have been the more consistent use of the Morse Fall Scale, the comprehensive training of staff, and the effective technological integration. These factors have improved the identification of risk factors, which in turn increased response times while reducing fall rates to 2.9 per 1,000 patient bed days. Several assumptions underlie the success evaluation: that falls are indeed reported accurately, with personnel feeling safe to do so; fall-prevention protocols, including the Morse Fall Scale, are uniformly applied across all units; the technology in place (bed alarms, EHR alerts) is functional and has been integrated into workflows effectively; and that staff received adequate training and are following protocols. Such assumptions are necessary to determine the impact of the QI initiative on the decrease of fall-related incidents and how it upholds the core values of Springfield General, such as safety, patient-centered care, and continuous improvement. Interprofessional Participants & Actions Quality improvement (QI) initiatives in the prevention of falls at Springfield General Hospital were significantly enhanced through contributions of an interprofessional team. Nurses, along with physical therapists and physicians, were all very integral in playing their parts within the initiative, giving each profession its own specific perspective. Nurses played a very integral role in identifying at-risk patients and executed fall-prevention protocols such as performing regular fall-risk assessments using the Morse Fall Scale (Baumann et al., 2022). Physical therapists also contributed through specialized interventions to enhance mobility and strength in the patients, which presumably mitigates falls. Physicians were able to offer insights about medication and overall health conditions that could predispose the patients to fall more than others. Feedback from these healthcare professionals was foundational for frequent meetings and input about the functionality of technologies such as bed alarms and EHR alerts. Together, their efforts helped enhance communication, create uniformity in treatment adherence, and time interventions around falls, resulting in a visible decrease in falls rates (Baumann et al., 2022). NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation However, even with these milestones, there existed areas of uncertainty and knowledge gaps that needed to be eliminated. For example, while the technology integration (e.g., bed alarms and EHR alerts) was generally well-received, concerns about alarm fatigue among staff emerged, potentially affecting their responsiveness (Baumann et al., 2022). Nurses reported that the frequency of alarms sometimes led to desensitization, making it harder to prioritize critical alerts. Although the Morse Fall Scale is widely used, some members of the team question whether it accurately accounted for all factors that contribute to fall risk, especially in patients who have complex medical histories. Additional training regarding the subtleties of fall risk and further data on exactly how specific patient populations respond to specific prevention strategies would have provided a more total conceptualization of the impact of the initiative. Further insights from the staff of all departments, and methods to further heighten technology integration, and the perfect usage and application of assessment tools may have possibly provided even better fall-prevention practices (Baumann et al., 2022). Additional

NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis Name Capella university NURS-FPX 6016 Quality Improvement of Interprofessional Care Prof. Name Date Adverse Event or Near-Miss Analysis The near-miss incidents and adverse events take a very significant place among healthcare concerns because it is a matter of substantial risk for the safety of patients. Adverse events are undesirable clinical outcomes unrelated to a patient’s underlying condition. Such adverse events include prolongation of hospital stay, causing irreversible damage and requiring critical interventions to prevent death. In contrast, near-miss incidents offer critical learning opportunities by revealing hazards narrowly avoided. Feng et al. (2022) report that annually, hospitals across the globe suffer 134 million adverse events, leading to 2.6 million deaths. Such dire statistics raise an alarm on how frequent and drastic the situation is, involving instances like patient falls, medication errors, pressure injuries, and hospital-acquired infections. These events are often a result of lapses in the alertness of healthcare professionals. All these can be either prevented or minimized if there is vigilance and adherence to safety measures. This case review will analyze the incident of a particular patient fall at Springfield General Hospital, its outcomes, and practical recommendations for reducing its chances of happening again in the future. NURS FPX 6016 Assessment 1 Adverse Event or Near-Miss Analysis Mr. John is a 72-year-old male patient admitted to the hospital after having undergone surgery to replace the right knee. He had a background of Type 2 diabetes mellitus and mild cognitive impairment. Upon admission, his vital signs were stable: BP 130/78, HR 75, and RR 16. After surgery, John was put on pain medication management and encouraged to engage in physical therapy. Nurse Clara, the orthopedic unit head nurse, did the initial fall risk assessment but failed to update it when John complained of dizziness from moving from his bed to his chair. However, Clara still assigned the junior nurse, Mia, to help John ambulate to the bathroom while adhering strictly to the four steps. Mia was attending to another patient and delayed response to the call light. Meanwhile, John, wanting not to wait, tried to get up alone to the bathroom. He was not steady on his feet and fell and struck his forehead to the floor. The staff attended promptly to John who was found confused and bleeding from a forehead laceration. A CT scan diagnosed John with a mild concussion and extended his hospital stay for five more days. This brought anger from John’s family toward the hospital staff, questioning why such a fall-prevention protocol had not been taken seriously. They filed a complaint against the hospital for negligence. Analysis of Implications of Adverse Event on Stakeholders The adverse event of John’s fall at Springfield General Hospital had wide-ranging implications for all stakeholders. In the immediate implication, John suffered from physical injury, delayed recovery, and emotional distress; in the long term, reduced mobility, increased dependency, and the fear of future falls. His family suffered from emotional turmoil, financial strain, and a loss of trust in the healthcare system. The effect of the incident on the interprofessional team was raised stress, scrutiny, and possibly blame: evidence of poor communication and lapses in safety practice. Hospital-level impacts included reputational damage, financial liabilities, and investments in corrective actions. The community’s confidence in the hospital’s safety standards was also affected and might affect health care-seeking behavior. Assuming that lapses in communication, incomplete patient monitoring, and insufficient adherence to safety protocols were causes of the event. There is also a strong assumption about the robust fall-prevention strategy, including the appropriate time assessment of risk and actual communication among the staff, which may have prevented the incident. Responsibilities include conducting a root cause analysis, providing immediate care, and transparently addressing the event with the patient and family. Preventive measures, including offering necessary training to the staff members, prompt responses to patients’ demands, and documentation improvements, are associated with preventing future incidents (WHO, 2020). This case underlines the interlink between the roles of different stakeholders and their associated requirement of a systemic approach to patient safety. The sequence of Events, Missed Steps, Protocol Deviation The adverse event of John’s fall was a result of deviations in the management rather than his condition. The missed critical steps comprised failure to reassess John’s risk for falling after he reported his feeling of dizziness, failure in communication by the nurses during the shift handover, and a delayed response to the call light. These lapses made John attempt to walk unobserved that led him to fall. Root cause analysis showed that there were lapses in the execution of fall-prevention protocols, including documentation and monitoring. The incident also showed lack of proactive measures by providing assistive devices for John or educating him on importance of raising a request for assistance. Had protocols been painstakingly followed, this would have been prevented. The interprofessional communication failures were central to this incident. Clear and structured handoffs would have communicated the elevated risk of falls with the next shift. Joint work among nurses and the physical therapy group would ensure a safer management of his mobility. The lack of documented real-time expectations and missed chances to address John’s dizziness points out knowledge deficits, specifically not appreciating how transient symptoms like dizziness can progress to an elevated risk of falls. Additional questions remain, such as whether staffing levels or workload contributed to the delayed response and whether the hospital’s fall-prevention training adequately prepared the staff. Addressing these uncertainties could provide deeper insights into preventing such adverse events in the future. Quality Improvement Actions and Technologies To avoid adverse events such as a fall by patients, implementation of evidence-based quality improvement actions and technologies will be required. One major action is routine fall risk assessments, using validated tools like the Morse Fall Scale, to identify which patients have specific risks and manage them appropriately (Kim et al., 2021). Staff members should participate in regular training sessions focused on fall-prevention protocols, including clear pathways and proper footwear,