Falls Organizational Structure

Organizational structure and culture in a health care organization is a complex phenomenon that reflects the social norms and beliefs of an organization. To effectively impact patient safety, health care organizations need to adopt a culture of safety. Organizations that practice high reliability, encourages a culture of safety. Adopting a culture of safety and high reliability is considered to be one of the most important factors in improving outcomes for hospitalized patients. High reliability organizations have a strong focus on patient safety, non-putative reporting of near-misses, and potential safety events. High reliability organizations promote 200% accountability. 100% accountable to the patient, and 100% accountable for an associates

The Nursing Quality Council and the Professional Practice Council recognized this, and have implemented an evidence-based falls prevention team and program. Patient assessment using a universal falls protocol was implemented. Every patient is assessed for risk to fall using the ABC risk for injury assessment and the Morse fall scale. Reassessment of the patient’s risk to fall is completed on each shift, since a patient’s condition can change rapidly. Spoelstra et al. (2013), found reassessment of a patient’s risk to fall as one of the key interventions to preventing falls. Delirium an underappreciated contributing factor for falls. When patients are agitated or confused assessment of the level of confusion using the Confusion Assessment Method or CAM is utilized. If the CAM score is positive, there are guidelines for treatment and prevention of delirium. This includes measures to minimize delirium such as maintain day and night schedules, orientation to time, activities, and event’s (Babine et al., 2016). Enclosure beds, TABS alarms, hourly rounding, and red slippers-socks that indicated the patient is at risk to fall are all utilized. If the patient continues to be confused and agitated medications are administered, the most effective is Seroquel and part of the delirium protocol. Family engagement is encouraged and a care-partner program was implemented where either family or specially trained volunteers stays with the patient. When a fall does occur, there is a post fall huddle to discuss the cause of the fall and what could have been done to prevent the fall is conducted. The Joint Commission (TJC) recommends the use of a post fall huddle as a way to promote a culture of safety and to review the root cause of a patients fall. (The Joint Commission [TJC],