Patient Falls

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Case Study Analysis - Patients Falls

Case Study Analysis - Patients Falls
Quality management departments collect and analyze data to ensure quality care that is safe and effective for patients. Positive outcomes are crucial for success, and are measured objectively to monitor, and revise improvement programs implemented. Regulatory and accreditation agencies set the standards for patient safety defining quality indicators that health care organizations measure, and evaluate to sustain accreditation with compliance. Data proves compliance with best practices and positive outcomes, increasing reimbursement and the number of individuals who will come to the organization for care. Administration leadership has found that it is necessary to understand quality indicators and measures of patient safety, and take accountability. The purpose of this paper is to analyze the case study on patient falls found in chapter 2, page 30 of Measuring Health Care (Dlugacz, 2006). Team C will examine the data collection measures used to monitor and revise quality improvement programs, regulation and accreditation agencies, and barriers that may prevent success.

Measures Used to Monitor and Revise

Data collection on patient safety is required by governmental agencies such as Centers for Medicare and Medicaid (CMS). Falls have become highly prioritized as a problem because they often cause fractures, surgery, head injuries, etc. Incidents of patient falls can increase patient length of stay because of the injuries that can occur causing unnecessary complications that will require further diagnostic tests, and patient care. Patient surveys may also have a negative impact on the organization because often the patient, or family will complain about his or her care, or malpractice suits may be filed.

Dlugacz (2006) states that valid measures define events that occur in circumstances where there were opportunities for the event to occur. The measurements used to monitor the number of occurrences of patient falls will illustrate and define the quality measure. Quality measures are the number of events, divided by the number of opportunities that a patient fall could have occurred. A quality management team can also break the number of events down further to assess how many falls resulted in patient injury, such as a fracture, the influence of medication as a cause, staffing, time of day, etc. Falls are measured objectively most often through incident reports, which are then investigated to assess cause, leading to preventative methods. The National Database of Nursing Quality Indicators (NDNQI) is often used to enable comparison nurse sensitive indicators, such as patient falls, and provides a benchmark for patient safety goals (Quigley, Neily, Watson, Wright, & Strobel, 2007).

Data collection methods for measuring patient falls helps health care professionals understand the scope of the problem to determine what is needed to improve this aspect of patient safety. Measurements are not standardized, unless all members understand what data is being collected, and measured (Dlugacz, 2006, p. 32). An organization may use databases, such as the NDNQI, to filter information for accountability to maintain a safe environment for all. Databases allow trends viewed from a financial and clinical standpoint, and provide a clear picture of what is occurring within the organization based on specific clinical variables, such as patient falls, contributing to operational decisions. Trends shown overtime enables an understanding of what was done differently, and how it compares to other organizations best practice. Administration can then compare numbers between the departments accurately and objectively. Once the problem is understood, improvements can be made and appropriate measures taken. Through assessment of the variables that may lead to a patient fall, the questions can be answered regarding why the fall...
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