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A gap analysis of falls prevention on a medical-surgical unit
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A gap analysis of falls prevention on a medical-surgical unit

Lorraine Wenzel
Master of Science (M.S.), Drexel University
14 May 2023
DOI:
https://doi.org/10.17918/00001975
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Abstract

Falls Cognitive impairment Fall prevention
A microsystem assessment was completed on a medical-surgical unit. One of quality initiatives that was identified as a problem in this microsystem was an increase in fall rates with 18 falls for the year. There is a need for change to decrease the metrics in patient falls. A gap analysis is completed after data from fall reports are collected to identify the gaps within the fall prevention program. The purpose is to decrease the fall rates by identifying the gaps and causes of falls and what needs to be altered within the current fall prevention program to prevent patient falls in the future. The data is collected to identify the gaps in the falls procedures that are reported. From January to March 2023 there were four falls. The results revealed that all the patients involved were cognitively impaired patients. Patients were found on the floor while the bed was alarming. Seventy-five percent of patients did not have patient education on falls prevention. Zero patients had fall prevention safety equipment utilized such as a telesitter. It is unknown if post-fall debriefings was a collaborative effort with team members. The analysis of these results entails the presence of language barriers, alarm fatigue, non-use of safety equipment, barriers to caring for cognitively impaired patients, and lack of education and communication of fall prevention strategies within the interprofessional team, patients, and families. Clinical implications of the evidence present the need for family involvement (Walker, 2004). This may include having a family member stay with the patient in the hospital. The safety needs of these patients involve specific planning of interventions beyond the fall risk assessment as risk factors are just as vital (Dykes et al, 2018). Reinforcement of safety equipment available such as telesitter. Furthermore, initiating consistent communication amongst the care team on the patient's fall prevention plan and reflection of the fall event with post fall debriefings is crucial in preventing a fall in the future and providing safe patient care (Hoke & Guarracino, 2016).

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