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The Road to Success: Prevention of Falls

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Lauren Hoth

on 16 April 2014

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Transcript of The Road to Success: Prevention of Falls

The Road to Success: Prevention of Falls
Leadership Theory
Situational Theory
Identify a Problem/Issue
Patient fell on the floor:
- Post-op TKA day #1
- Wife was trying to assist him to get to the bathroom
- Nurse in the hall was called in to assist
Situation resulted in a
staff assist to the floor
SWOT Analysis
Develop a Plan
Barriers to Change
Evaluation of the Plan
Presented by: Lauren Hoth & Kelley Pickens
-Lack of compliancy
-Lack of nurses’ knowledge
-Lack of caring attitude
-Lack of availability of support staff
-Lack of equipment
-Health status of patient
-Education of interdisciplinary staff
-Failure to communicate
-No definitive research regarding efficacy of interventions

Ang, E., Mordiffi, S., & Wong, H. (2011). Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. Journal Of Advanced Nursing, 67(9), 1984-1992. doi:10.1111/j.1365-2648.2011.05646.x

Everhart, D., Schumacher, J., Duncan, R.P., Hall, A.G., Neff, D.F., & Shorr, R.I. (2014). Determinants of hospital fall rate trajectory groups: A longitudinal assessment of nurse staffing and organizational characteristics. Health Care Management Review. pp 1-9.

Graham, B. C. (2012). Examining Evidence-Based Interventions to Prevent Inpatient Falls. MEDSURG Nursing, 21(5), 267-270.

Titler, M.G., Shever, L.L., Kanak, M.F., Picone, D.M., & Qin, R. (2011). Factors associated with falls during hospitalization in an older adult population. Research and Theory for Nursing Practice: An international Journal. 25(2); pp 127-152.

Tzeng, H. (2011). Nurses' Caring Attitude: Fall Prevention Program Implementation as an Example of Its Importance. Nursing Forum, 46(3), 137-145. doi:10.1111/j.1744-6198.2011.00222.x

Tzeng, H., Yin, C., Anderson, A., & Prakash, A. (2012). Nursing Staff's Awareness of Keeping Beds in the Lowest Position to Prevent Falls and Fall Injuries In an Adult Acute Surgical Inpatient Care Setting. MEDSURG Nursing, 21(5), 271-274.

Weinberg, J., & Proske, D., Szersen, A., Lefkovic, K., Cline, C., EL-Sayegh, S., Jarrett, M., Weiserbs, K., (2011). An inpatient fall prevention initiative in a tertiary care hospital quality and patient safety . The Joint Commission Journal on Quality and Patient Safety, 37(7), pp 318.

-Safety huddles
-Fall risk markers
-Documentation of fall risk every shift
-Hourly rounding
-Close to nursing station
-Bed/chair alarms
-Answering call lights promptly
-Assistive Devices

-Access to facilities
-Lack of knowledge & education
-Resources available for training
-Lack of compliancy
-Patient education
-Agency/float pool/resource nurses
-Continuing education or in-services
-Fall Prevention Committee
-Medication review
-Difficulties with availability of support staff
-Health status of patients
-Leadership commitment
-Financial concerns

> Patient falls on the floor will decrease by two falls during each quarterly review after the implementation of new protocol

> If a patient falls there will be a debriefing within a week of incident with the staff nurse, charge nurse, supervisor, and another administrator to look at the precautions in place and how the situation was handled by staff and patient after the event.

> On the post-stay survey, patients will report an increased awareness of possible fall and an increase of staff talking with them about falls before and during hospital stay
BEFORE surgery, in the surgeons office, patients need to be introduced to they safety precautions they'll encounter and the importance of them

Patient's who've had problems with compliance to call light use will be put on a bed alarm, regardless of mental status or physical abilities

Patient medications need to be reviewed closer- reducing elderly patients on sleeping aids and giving furosemide (Lasix) three hours earlier was proven to decrease falls

The documentation of falls and circumstances provoking the fall need to have a very standardized language associated with it

Post-fall there will must be a meeting with between floor staff member involved, charge nurse, supervisor of the floor, and an administrator. There must also be an opportunity for feedback from staff involved.

Additional meeting monthly amongst administrators impacted the fall rate--discussion should revolve around the root cause/ circumstances surrounding cause of the fall

1. How well did the transition and implementation of new protocol go during "move" phase
2. Feedback
3. Did we reach our 3 main goals?

Force-Field Change Model
-Caring attitude of nurses'
-Intrinsic satisfaction
-Fall prevention is related to nursing process
-Education pre/post op
-Interdisciplinary teamwork
1. Unfreeze

2. Move

3. Refreeze
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