Safety, Quality, and Informatics

Safety, Quality, and Informatics: Slips and Falls

Some estimates have placed patient safety as one of the leading causes of death alongside cancer and heart and cardiovascular diseases. The western population trends are characterized by high numbers of aging citizens, which has led to significant strain on the healthcare system (Dykes, et al., 2010). With a strained healthcare system, patient safety is now one of the core skill required of all healthcare practitioners working in all facilities. Safety in organizations is intended to keep both the patients and the healthcare providers free of harm caused by the nature of the environment (Crenshaw et al., 2017). The institution that is under consideration in this paper has built a culture of safety by setting outpatient safety measures. The organization has the responsibility of providing the safety program and ensuring that sustainability of the culture of patient safety has been established. The head of the organization is a registered nurse with a postgraduate degree and robust experience in clinical practice. This paper will address one patient safety issue; slips and falls, compare the currently used processes for addressing slips and falls, in addition to the legal and ethical implications of not addressing the concern. Additionally, the essay will look into the use of technology to curb patient safety issues in addition to discussing the barriers to organizational change and what strategies can be applied to overcome the identified challenges.


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Patient Safety Issue: Slips and Falls

            Slips and falls are a source of significant burden to communities and governments throughout the world. In the United States, the slips and falls form the second leading cause of accidental death after motor vehicle-related accidents (Dykes et al., 2010). The falls result in higher financial costs, mortalities, morbidity, and poor quality of life. For instance, there more than 25,000 deaths in 2009 and more than 9 million ED visits associated with slips and falls (Lockhart, 2015).  According to Crenshaw et al. (2017), more women are at a higher risk of falling and sustaining injuries compared to men. The authors also acknowledge the significance of studying the circumstances, the impact locations, and the risk factors associated with slips and falls to develop effective interventions to minimize the injuries to high-risk populations. Kuhlenschmidt et al. (2016) provide that despite the significant studies being completed on the risk factors connected with falls in admitted patients, there is need for further inquiries on the perceptions of the hospitals and the hospitalized patients on the most prevalent risk factors for falls and the chances of sustaining injuries (Kuhlenschmidt et al., 2016).  According to Crenshaw et al. (2017), the risk factors associated with falls continue to exist despite the understanding that prevention mechanisms involve creating awareness to the nurses and other caregivers as well as the patients on the risks for falls and the possible injuries that are caused by falls.  Studies have indicated that nurses play a crucial role in preventing patient falls and injuries through education. While studies have indicated that the safety of patients is the primary role of nurses, concerns have been raised that most institutions do not include the nursing professionals in the decision-making teams and hence there is a little influence in remedying the challenge (Dykes et al., 2010).

            The organization that was considered in this review has instituted several measures to handle slips and falls as a patient safety issue. The research into the common causes of fall identified in hospitals involved normal walking, running and hurrying, descending and ascending stairs, getting up from a chair and turning (Crenshaw et al., 2017). The institution under review has sought to train the nurses on the various mechanisms that can be applied to reduce the instances and impacts of falls. One such procedure that is being used is the protective arm movements to help reduce the incidence of fracturing the hip. This was specifically useful when the falls had a sideways orientation; however, this had a potential risk to fracturing the bones near the elbow. The institution also has a program where the patients are taught on how to recover from a fall and the most common methods included backward chaining and sequential teaching and stepping responses. The nurses are also tasked with providing the patients with fall prevention care by ensuring the floor surfaces are clean and dry, the patients have walking aids, restricting movements of the patients, and removing obstacles from the pathways. Besides addressing the methods of recovery and protecting oneself through education, the institution has also embarked on addressing the built environment risk factors that may increase the odds of falls. The institution has enhanced the lighting, altered the surfaces of the areas commonly visited by patients such as the washrooms, and pathways to increase friction forces to prevent slips.

Legal and Ethical Consequences of not Addressing the Patient Safety Issue

            The dynamism and the sophistication of the healthcare system present serious legal and ethical challenges to nurses tasked with preventing falls in institutions (Pozgar, 2019). The nurses have the task of fall prevention and ensuring that the safety of the patients is catered for. The dilemma in fall prevention includes the need to restrict and limit the movement of the patients as observed from the maleficence against the autonomy of the nurse actions towards the patient (Pozgar, 2019). The nurses are expected to exercise patient autonomy by respecting the needs and desires of the patient. However, this should not be an excuse to allow the patient desires to cause distress and lead to falls. In caring for the patients, the nurses are required to always act in a manner that is likely to benefit the client and sometimes, the need to protect the client from possible slips and falls may negatively impact the autonomy of the patient, but is likely to benefit them in the long term. The requirement to act then ethically is a balancing act that asks the nurses to be in collaboration with other team members caring for patients before making the final decisions when the said decision has an ethical implication (Pozgar, 2019).

The failure to uphold the ethical and legal requirements while caring for the patients is associated with malpractice suits. Failing to exercise the required professional standards including clearing the pathways, providing walking aids, and allowing movements that present a risk for falls may be considered to be negligence on the part of the nurse if such omissions lead to fall (Pozgar, 2019). Equally, it is essential that slips and falls are reported, the moment they occur to help establish if any harm has been caused. Failure to report such incidences, however, minor they may appear, constitutes unethical practice that is against the legal and ethical expectations of a nurse (Dykes et al., 2010). The failure to report such incidences also forms the basis for a negligence lawsuit. Medical negligence is the underpinning theory for which a nurse can be sued and found guilty of hospital falls. This charge results when the nurse deviates from the professional standards expected of them and in the process causes injury to a patient (Pozgar, 2019).

Evidence-Based Interventions to Improve Patient Safety

Various factors such as limited staff and patient education and the processes for quality improvement are essential factors limiting the adoption of the necessary processes to enhance patient safety and reduce the risks of falls. Patient safety associated with falls can be addressed with effective training of the nurses who are in charge of the patients (Miake-Lye et al., 2013). The training program should emphasize the need for the nurses to identify the risk factors for slips and falls, the importance of fall prevention, the actions that one should take to ensure their safety, and how to recover from falls (Miake-Lye et al., 2013). The nurses will then be required to practice these learning outcomes with their patients regularly. The patients should be encouraged to call for help wherever they need one to avoid taking unnecessary risks.

The management of patients is a sophisticated process that involves various steps and individuals. With the use of technology, end-to-end management can be achieved where there is a seamless flow of information in the process (Miake-Lye et al., 2013). IT takes away the burden of the complexity of clinical decision making and enhances access to information, organize it and identify the associations between the pieces of information. Technology can also allow the nurses to quickly respond to calls from the patients who need help by using the call lights (Dykes et al., 2010). Technology can be used in teaching to simulate the falls and slips and how the nurses can help the patients recover from the falls without causing further injury.

Organizational Barriers to Change and How to Overcome

The barriers to change for an organization arise from 3 different sources: the targeted institution, the change initiated and the affected employees. The first significant barrier is the resistance to change, which comes from the uncertainties and the outcomes that may be caused by the change (Goetsch & Davis, 2014). People fear that they may not cope with the demands of the new environment. Lack of communications skills from the management can lead to people fear venturing into a territory they are unfamiliar with. The management, on the other hand, may be concerned with the lack of sufficient resources to deal with the outcomes of the change. Besides, when an organization has bureaucratic tendencies, it will tend to mandate change where the employees should take orders without question (Goetsch & Davis, 2014). This management style sees the top making decisions without the input from the bottom and in most cases, leads to failed change. The resources required for change including the financial consideration, the technology required for implementing the change and the failure to clearly define the vision for the organization presents real barriers to change in organizations (Goetsch & Davis, 2014). The push for instant success from the management is a failure to realize that cultural change is not an instant occurrence; instead, it should have realistic timelines and clear targets to allow for progress monitoring and evaluation.

The first step in overcoming the challenges is realizing their presence, the reasons for their existence, and the means of overcoming them. The top management of the organization must be committed to the change and help the course by adopting an effective communication strategy. They must make a case for the benefits of the proposed change and must have the trust of the employees in their action (Goetsch & Davis, 2014). The management must establish beforehand the nature and quantity of resources required to make the change possible. They must also understand why any previously attempted change failed and be open-minded and acknowledge the interdependence of the social systems in the organization.

Encouraging and fostering a flexible and adaptable culture. The management should understand the principles to the resistance of change that includes knowing the reasons for resistance, look at resistance as being a natural response to a contemplated change and this is regardless of whether the change is positive or negative. It is necessary that proper communication of the what, why, how, when of change is done to eliminate the resistance coming from the employees ‘not knowing’. For the ‘not able’ sphere, the management should look to train, educate and acquisition of new skills. For those ‘not willing’ it is recommended that goals, measurements, reward and coaching systems are established and soliciting of feedback.


Patient safety forms one of the critical functions of healthcare facilities and indeed, the entire system. While there are many issues that influence patient safety, slips and falls rank among the greatest cause of concern for the care providers. Slips and falls occur from various sources including poor lighting, poor and less friction in surfaces, lack of clearing obstacles, lack of sufficient training of nurses and patients on the risk factors and failure to provide the necessary equipment to aid the patients in movement. Organizations should take a lead role in ensuring that they have an environment in place that encourages prevention of slips and falls through creating an interdisciplinary collaboration to address the issue and encouraging nurse training.


Crenshaw, J. R., Bernhardt, K. A., Achenbach, S. J., Atkinson, E. J., Khosla, S., Kaufman, K. R., & Amin, S. (2017). The circumstances, orientations, and impact locations of falls in community-dwelling older women. Archives of Gerontology and Geriatrics73, 240-247.

Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F., … & Middleton, B. (2010). Fall prevention in acute care hospitals: a randomized trial. Jama304(17), 1912-1918.

Goetsch, D. L., & Davis, S. B. (2014). Quality management for organizational excellence. Upper Saddle River, NJ: pearson.

Kuhlenschmidt, M. L., Reeber, C., Wallace, C., Yanwen, C., Barnholtz-Sloan, J., & Mazanec, S. R. (2016). Tailoring education to perceived fall risk in hospitalized patients with cancer: A randomized, controlled trial. Clinical Journal of Oncology Nursing, 20(1), 84-89. doi:10.1188/16.CJON.84-89

Lockhart, T. (2015). Slips and falls.

Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine158(5_Part_2), 390-396.

Pozgar, G. D. (2019). Legal and ethical issues for health professionals. Jones & Bartlett Learning.


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