Procedure Revision and Hospital Policy

According to estimates, almost one million people die in US hospitals each year (Bouldin et al., 2013). Falls occur when a patient falls to a lower level inadvertently. Many of these falls end in damage, which has a substantial impact on the patients' many elements of their quality of life (Miake-Lye, Hempel, Ganz, & Shekelle, 2013). This research aims to address the issue of falls in hospitalized patients, as well as the implications for patient safety. The paper examines existing literature on the aspects of organizations that promote a safe culture, as well as a project plan to assist in the implementation of these practices in a similar situation. “Lewin’s Change Theory” has notably been used to detail the process of initiating change to the existing guidelines in a bid to enhance patient safety. Lastly, a method for evaluating the success of the project is given followed by a conclusion of the entire paper with particular emphasis on the intended outcomes of the proposed revision of the practice guidelines.

The Problem

Falls among hospitalized patients is a common problem that has an impact on patient safety. Approximately 35% of inpatient falls result in injury while about 5% of the falls result in serious injuries which are potentially fatal (Bouldin et al., 2013). Examples of such damages caused by falls include subdural hematomas and other traumatic brain injuries, fractures, lacerations, bruises among others (Bouldin et al., 2013). Falls are not only restricted to the elderly and frail patients who possess the significant risk factors. Instead, any patient of any age can be predisposed to falls as a consequence of physiological changes rendered on their bodies by their medical conditions, procedures, medications, etc. The impacts of falls among hospitalized patients cannot be understated. In addition to the physical injuries, there is an extended length of stay in the hospital for these patients. Miake-Lye et al., (2013) reports that on average, the hospital-stay time of patients who get serious injuries resulting from falls is extended by 10days. As a result, there are significant costs accrued in the form of patient care costs for these patients as compared to their peers after an adjustment for both clinical and nonclinical confounding factors (Miake-Lye et al., 2013). Hospital resources may also be used to cater for lawsuits when legal complaints are raised against a health service provider. Further, there is a two to three times probability of falling for inpatients who have fallen before (Bouldin et al., 2013). As such, these patients have an inherent fear of falling which results in self-imposed activity restriction (Bouldin et al., 2013). Eventually, this commences a cycle of decreasing functional ability among these patients. Prevention of falls is undoubtedly an issue that warrants concern in hospital settings. The point, however, is still a problem in hospital settings despite efforts to curb the menace and therefore, warrants interventions that utilize simultaneous strategies aimed at reducing it.

Background & Literature Review

As previously stated, falls account significantly for injuries witnessed in hospitalized patients. Falls are attributable to risks which can either be intrinsic or extrinsic. Intrinsic factors predisposing patient to falls relates to their physical state or their overall level of wellbeing (Miake-Lye et al., 2013). For instance, issues such as their age, gender, balance, ailments such as arthritis affecting on their level of incapability, etc. Extrinsic factors relate to the patient's environment such as the lighting levels, the slipperiness of hospital floors and other contributory factors (Miake-Lye et al., 2013). The bottom line, however, is that most of these risk factors can be assessed, and appropriate measures taken to prevent most of these patient falls. In that regard, organizations with a culture of safety have a shared commitment by health care providers and individual patients to foster safety-promoting behaviors. In such organizations, leaders raise awareness of the obligation of care providers in mitigating falls among patients by incorporating safety practices in the continuum of care (Grol, Wensing, Eccles, & Davis, 2013). Such organizations have interdisciplinary teams which are trained and tasked with reduction of falls by carrying out risk assessment using standard validated tools (Grol et al., 2013). Based on their unique identified falling risks, these patients receive individual plans of care and other suitable interventions. Besides, such organizations practice and apply interventions with demonstrated efficacy, for instance, educating patients on how to use assistive devices when in need of help such as toileting (Miake-Lye et al., 2013). In case of unpredictable falls, a post-fall management is conducted to inform efforts geared towards the improvement of future interventions (Grol et al., 2013). In such ways, cases of falls among hospitalized patients are adequately mitigated.

Project Plan

Implementation of sustainable solutions for promoting the safety of patients is ingrained in principles of teamwork, effective leadership, and change in behavior among the stakeholders involved (Grol et al., 2013). In this regard, there arises a need to promote change to address the several factors contributing to patient falls in the hospital of reference. Among the pertinent issues requiring procedure revision is in carrying out the risk assessment for falling where there are inconsistent ratings among the caregivers who use the risk assessment tools (Grol et al., 2013). Using the “Lewin’s Change Theory," the revision employs a rational-empirical approach whereby initially, in the unfreezing stage, staff will be trained and sensitized on the merits of using standardized assessment tools to help them shun their old practices. Further, this will be followed by an integration of the standardized validated tools into the electronic medical records of patients. In this way, also, both the nurses and the relevant ancillary staff will be able to access either party's charting details which have been shown to enhance consistency (Miake-Lye et al., 2013). Also, of note is the inconsistent sharing of information about a patient’s risk of falling among caregivers. Possible solution to this included in the revision guidelines is the use of whiteboards to communicate to staff on all shifts about patients with a risk of falling. Also, on the same issue of inconsistent communication among caregivers, there arises a need to push for alerts to be incorporated into electronic medical records of patients who are deemed to be at risk of falling. Another feasible solution would be an initiation of bedside shift reports that move along with the patient to alert other staff of concerns of falling if the patient is at risk (Miake-Lye et al., 2013). It is also imperative that the leaders consider providing adequate lighting in places that the patients use as well as a scheduled rounding protocol for patients who require frequent toileting (Grol et al., 2013). Lastly, attention will also be drawn to the importance of leaders of healthcare organizations in promoting an organizational culture that values the safety of their patients. The support of the leaders is particularly crucial because, besides the establishment of goals and objectives geared towards achieving zero falls, they provide the resources and support needed for the program and provide good examples for other staff members (Grol et al., 2013). Also, they help to monitor if the staff members are adhering to the implemented care protocols (Grol et al., 2013).

The Institute of Medicine identifies several important opportunities for enhancing patient safety through mitigating falls. For instance, IOM advocates for individualized interventions based on the risks identified from the risk assessment procedure (Miake-Lye et al., 2013). It also recommends that staff members should be taught about fall reduction programs. For the patients and their families, they should be educated about strategies to reduce falls (Miake-Lye et al., 2013). Ultimately, as a quality improvement measure, activities geared towards fall reduction should be evaluated for their potency.

Method of Evaluation

Evaluation of the project outcome is critical in assessing whether the fall reduction programs are productive and of benefit to the participants or in other words, assessing the general value of the program (Miake-Lye et al., 2013). In this case, the rate of falls and potential resultant injuries and the overall adoption of fall prevention practices are critical components of quality improvement of the program. They are crucial parameters for evaluating the success of the implementation project as well as learning from the successes and the challenges herein. In the case of this project, it is anticipated that there will be a decrease in the rate of falls among the patients. It is also expected that the number and severity of injuries due to falls will decrease significantly. Trained observers can also be used to identify if fall prevention/reduction practices are being instituted correctly, which is critical in determining if the recommended measures are to be productive.


Undoubtedly, falls among inpatients is a common problem that affects patient safety. Falls have detrimental impacts on the quality of life of the patients. Risks which are attributable to these in-hospital falls are either intrinsic or extrinsic. Consequently, there is a need for implementation of sustainable solutions for promoting the safety of patients. Among the solutions which have been put forward to modify the existing policies include standardization of risk assessment tools, the establishment of adequate channels of sharing information about vulnerable patients and promotion by leaders of an organizational culture that values the safety of their patients. Indeed, corporate programs geared towards achieving these goals ultimately deserve constant evaluation to ensure that they are in keeping with the set objectives. The review is in the form of an assessment of whether the expected results are met. In that regard, the proposed policy revisions anticipate a decrease in the number and severity of fall-related injuries as well as the rate of falls. With those mentioned above achieved, the project would thus be a success.


Bouldin, E. D., Andresen, E. M., Dunton, N. E., Simon, M., Waters, T. M., Liu, M., ... & Shorr, R. I. (2013). Falls among adult patients hospitalized in the United States: prevalence and trends. Journal of patient safety, 9(1), 13.

Grol, R., Wensing, M., Eccles, M., & Davis, D. (Eds.). (2013). Improving patient care: the implementation of change in health care. John Wiley & Sons.

Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient Fall Prevention Programs as a Patient Safety StrategyA Systematic Review. Annals of internal medicine, 158(5_Part_2), 390-396.

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