Patient Quality and Safety Indicators: Patient Falls

This paper comprehensively extrapolates patient falls as a patient quality and safety concern and how it can be used as an indicator of the same in a given healthcare setting. It also provides potential solutions to patient falls and how to utilize PDSA small-scale quality cycles to solve patient falls among mentally ill patients in a mental health unit.

Running Head: PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 1
Patient Quality and Safety Indicators: Patient Falls
Name
Institution
Date

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 2
Patient Quality and Safety Indicators: Patient Falls
Introduction
Sammer, et al., (2010) sort to find out what is patient safety culture and indeed contends
that despite the remarkable efforts healthcare stakeholders take to elevate patients’ healthcare
outcomes, there are concerns as to whether these care efforts meet minimum quality and safety
standards for patients. With a team of healthcare experts, McLoughlin, et al., (2006) developed a
comparable patient safety and quality indicator framework to assist nations under the
Organization for Economic Co-operation and Development (OECD) track and monitor the same
in their healthcare systems. McLoughlin, et al., (2006) deduced that patient falls is one of the
most fundamental yet detrimental patient quality and safety concern. Healthcare institutions
ought to make efforts to minimize patient falls since quality care is critical to both patients and
the organizations. Against this backdrop, this paper will comprehensively extrapolate patient
falls as a patient quality and safety concern and how it can be used as an indicator of the same in
a given healthcare setting. Additionally, this paper will endeavor to utilize 3 small-scale PDSA
quality cycles to solve patient falls and injuries and subsequently improve patient quality and
safety outcomes in the mental health unit.
Patient Falls; Definition
Many definitions of falls and associated injuries have been advanced with many scholars
attributing falls to intrinsic and extrinsic factors. Intrinsic factors are associated with a
physiologic origin while extrinsic factors originate from the environment and other hazards
(Rheaume & Fruh, 2015). Comprehensively understanding these risk factors is critical at
facilitating the formulation of preventive strategies to patient falls. Agostini, Baker, Inouye, and
Bogardus (2001) define patient falls in inpatient settings as “Unintentionally coming to rest on

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 3
the ground, floor, or other lower level, but not as a result of syncope or overwhelming external
force.” However, an all-inclusive definition of a ‘fall’ that takes care of both intrinsic and
extrinsic factors is provided by American Nurses Association-National Database for Nursing
Quality Indicators (ANA-NDNQI) that define a ‘fall’ as “An unplanned descent to the floor with
or without injury”[American Nurses Association, 2005].
From this later definition, falls can either result to injuries or not with incident reports
using different terminologies to describe the levels of injuries. The ANA-NDNQI categorize fall-
related injuries as none-no injury, minor-slight injury requiring simple intervention, moderate-
considerably serious requiring splints or sutures, major- significantly serious requiring surgery
casting and other examinations and death-fatal. Having a formidable definition of patient falls
and levels of injury resulting from the fall is instrumental in determining what constitute a fall
and subsequently helping in calculating rates of patient falls (Healey & Darowski 2012).
Patient Falls; Measurement as a Patient Safety Indicator
Australian Commission on Safety and Quality in Health Care (ACSQHC) [2012]
recognize patient falls as one of the primary hospital-acquired complications which therefore
become a formidable quality and safety indicator in the Australian health care system. Patient
falls are a federal priority in improving patient quality and safety and they are measured through
the National Health Performance Framework (NHPF) [ACSQHC, 2012]. The main focus of the
ACSQHC, (2012) falls measurement are falls that result to general bone fractures, neck and
femur fractures, and intracranial hemorrhage. The Agency for Healthcare Research and Quality
(AHRQ) [2018] point out that the most optimal measure of patient falls in inpatient settings is
one that comparisons can be made over time and across different healthcare facility units to
determine whether change is improving.

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 4
The agency recommends that patient falls be determined as a rate, specifically, the rate of
falls per 1000 occupied bed days. In the same way, healthcare practitioners can determine the
rate of injurious falls per 1000 occupied bed days. Patients’ falls specific details must be
comprehensively documented and measurement literally emanates after the actual physical
counting of the number of falls as well as number of occupied bed days in a specific timespan
like a month [AHRQ, 2018]. According to the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) [2015] patient falls are categorized under the sentinel events with the
numerator being the number of falls resulting in injuries and the denominator being all hospital
admissions.
Patient Falls Literature Review
Patient falls are by and large some of the commonest yet preventable adverse facets of
inpatient and acute hospital care. A survey conducted on England’s National Health Service
(NHS) and whose results were notified in the NHS’s National Reporting and Learning System,
indicated that there were 314,314 patient falls in NHS hospitals. This figure accounted for 19%
of all incidents the system was notified of [NHS National Reporting and Learning System,
2015]. In the U.S. health facility system, patients falls incidents have been deduced to be
between 700,000 and 1000, 000 annually with 30-50 % associated with injuries [Agency for
Healthcare Research and Quality, 2013].
The Australian Institute of Health and Welfare, (2014) reported that patient falls in both
the public and the private healthcare facilities were 298,709 while in New South Wales (NSW)
public hospitals alone there were 27,073 patient falls in 2013. In the period between 2015 and
2016, the Australian healthcare system reported 34,000 falls which happened at the rate of 3.2
per 1000 separations. The public sector hospitals reported more falls per 1000 separations which

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 5
happened at the rate of 4.6 per 1000 separations while the private hospitals reported a rate of 1.3
per 1000 separations [Australian Institute of Health and Welfare, 2017].
Healey, et al., (2013) observe that the old age, severity of illness as well as unfamiliar
surroundings in healthcare facilities are the major predisposing risk factors of patient falls and
falls’ consequences. However, elderly and frail patients are not the only ones that are vulnerable
to falls in healthcare settings. Any patient that is perceived to be of considerable health stature is
also prone to a fall particularly due to physiological changes, medications effect, medical
condition, diagnostic testing, and surgical procedures which have the potential of weakening the
patient or leaving them confused. Patients are likely to suffer harms such as soft tissue injuries,
fractures, psychological trauma, head injuries, death, extended hospital stays and cost of
healthcare escalations (Dunne, Gaboury, & Ashe, 2014; Ambutas, Lamb & Quigley 2017).
Coutinho, Bloch, and Coeli (2012) in a study involving older persons above the age of 60
observed a one-year cumulative mortality of 25.2% amongst all older persons with fall
associated fractures. Wong, et al., (2011) estimated that injured patients from falls are likely to
spend an additional 6.3 days in the hospital while Galbraith, et al., (2011); Haines, et al., (2013)
estimated that it can cost up to $14,000 per fall with injury.
JCAHO [2015] through its Sentinel Alert Event publication contend that falls with severe
injury are persistently amongst the top 10 sentinel events which are reported to the commission’s
Sentinel Event database. Since 2009, 465 falls reports with injuries have been reported with
many of these injuries occurring in healthcare settings of which 63% resulting in death and the
rest sustaining injuries. The JCAHO [2015] further indicate that the most contributing factors to
patient falls include communication failures, lack of effective leadership, physical environment
deficiencies, ineffective staff management practices, inadequate assessments and failure to

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 6
adhere to protocols and safety practices. To this end, there is a need to come up with patient
quality and safety improvement strategies that can minimize falls and its adverse effects.
Potential Solutions to Patient Falls
JCAHO [2015]; [ACSQHC, 2012] has suggested several actions that healthcare
institutions can utilize to prevent and minimize falls and injuries related to falls. These include
leading efforts to raise falls prevention awareness; establishment of an interdisciplinary falls
injury prevention team; institution of standardized tools to identify falls’ risk factors. Moreover,
the commission deems coming up with patient-specific plans of care such as effective
communication and one-to-one patient education as very instrumental. Furthermore, conducting
effective post-fall management practices such as transparent reporting of falls and falls’ analysis
can inform further improvement. JCAHO [2015] asserts that preventing hospital falls calls for
the commitment of healthcare facility's leaders as well as the formulation of systematic and data-
driven strategies targeting particular health care settings and specific patient populations. The
Plan-Do-Study-Act (PDSA) quality cycles framework is such one systematic and data-driven
approach instrumental in the improvement of patient quality and safety indicators (Varkey, et al.,
2009).
PDSA Small-Scale quality cycles
Three fundamental questions are utilized by Plan-Do-Study-Act (PDSA) Quality Cycles’
framework to inform the change process and improvement in patient quality and safety
indicators in which case a model of improvement emanates (Curnock, Ferguson, McKay, &
Bowie, 2012). These questions are; What are we trying to accomplish? How will we know that a
change is an improvement? What changes can we make that will result in an improvement?

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 7
The Improvement Guide, API, 2009.
Employing PDSA Small-Scale quality cycles to Solve Patient Falls among Mentally Ill
Patients in a Mental Health Unit
Fundamental Questions
What are we trying to
accomplish?
1. Come up with patient-specific plans of care such as effective
communication, one-to-one patient awareness of falls and related injuries
to minimize the same by 70% of all reported cases in a six month period.
2. Establish of an interdisciplinary falls injury prevention team to develop
quality and safety improvement strategies related to patient falls reduction
and subsequently minimize falls by 80% of all reported cases in a six
month period.

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 8
3. Improve the physical mental health unit environment by removing patient
falls risk factors and subsequently minimize falls by 90% of all reported
cases in a six month period.
How will we know
that a change is an
improvement?
1. Patient falls reduction with patient being more aware falls’ dangers and
falls’ risk factors.
2. Healthcare practitioners demonstrate skilled abilities of handling mentally
ill patients requirements including falls’ cases
3. Mental health patients' abilities to locate falls risk factors in the mental
health unit
What changes can we
make that will result
in an improvement?
1. Streamline communication between healthcare practitioners and institute
passionate one-to-one patient education.
2. Healthcare providers’ training on the how to handle falls among mentally
ill patients.
3. Having low-beds, non-slippery floors and supporting gadgets especially in
washing rooms.
PDSA quality cycles

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 9
PDSA CYCLE 1: Objective; Minimization of Patient Falls by at least 70% of all previously
reported cases in a six month period.
Plan rate The Improvement being
sought
Minimization of falls by 70%
of all previously reported
cases in a six month period by
improving patient-specific
plans of care such as effective
communication and one-to-
Carry out the plan
Collect data
Analyse data
Complete data analysis
Summarize what was learned
Change or test interventions
Define objectives,questions and
indicators
Plan data collection
Plan for the next cycle and decide
whether change will be replicated
Act Plan
DoStudy

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 10
one patient awareness of falls
Time Scheduling A Time Planner Template
Measure of patient safety and
quality indicators
Reduction in the % of patient
falls per 1000 bed separations
monthly
Select change Tighten effective
communication and patient
education
Do Implement change Effective communication,
education and falls awareness
Study Evaluate change Improved communication and
awareness of patient falls and
associated injuries.
Reduced number of falls
reported within the period.
Act Adopt, reject or modify the
change plan
Positive improvement as
evidenced by improved
communication and falls
awareness.
Increased minimization of
falls per 1000 bed separations
by 60% of previous reported

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 11
incidences.
PDSA CYCLE 2: Objective; Minimization of Patient Falls by at least 80% of all previously
reported cases in a six month period.
Plan The Improvement being
sought
Enhance healthcare providers’
skills and capacity to
minimize patient falls by 80%
of previously reported cases in
a six month’s period
Time Scheduling A Time Planner Template
Measure of patient safety and
quality indicators
Reduction in the % of patient
falls per 1000 bed separations
monthly
Select change Capacitating healthcare
providers through training and
education on handling
mentally ill patient falls
Do Implement change Train and educate healthcare
practitioners
Study Evaluate change % of healthcare practitioners
that can correctly handle
mentally ill patient’s falls and
injuries resulting from those

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 12
fall.
Act Adopt, reject or modify the
change plan
Positive progress as proved by
improved healthcare
practitioner’s skills and
capabilities in handling
mentally ill falls and injuries.
Increased minimization of
falls per 1000 bed separations
by 70% of previous reported
incidences.
PDSA CYCLE 3: Objective; Minimization of Patient Falls by at least 80% of all previously
reported cases in a six month period.
Plan The Improvement being
sought
Improve the physical mental
health unit environment by
removing patient falls risk
factors and subsequently
minimize falls by 90% of all
reported cases in a six month
period.
Time Scheduling A Time Planner Template
Measure of patient safety and Reduction in the % of patient

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 13
quality indicators falls per 1000 bed separations
monthly
Select change Physical mental health unit
environment improvement by
removing patient falls risk
factors
Do Implement change Having low-beds, non-
slippery floors and supporting
gadgets especially in washing
rooms
Study Evaluate change Number of mental health
patients with abilities of
locating falls risk factors in
the mental health unit
Act Adopt, reject or modify the
change plan
Positive improvement as
evidenced by increased
number patients able to locate
falls’ risk factors.
Increased minimization of
falls per 1000 bed separations
by 80% of previous reported
incidences.

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 14
Evaluation of the PDSA Quality Cycles
The Plan-Do-Study-Act (PDSA) quality cycles framework utilize quantitative statistical
information and different qualitative causes of action, tasks and activities with varying
complexity and methodological rigor to develop and implement small-scale interventions that
lead to improvement in health care outcomes of patients (Gillam & Siriwardena, 2013). Small-
scale interventions that showcase improvement in healthcare outcomes are then replicated to
produce overall positive healthcare outcomes for all patients (Siriwardena & Gillam 2014). In
this clinical problem, qualitative data can be sourced by conducting surveys, observation, issuing
questionnaires and engaging in focused group discussions while quantitative data can be
obtained by physically counting the number of falls and the number of occupied beds in a
particular month and calculating the rates and percentages. Improvement in patient quality and
safety is reported by there being an increased percentage of minimization of patient falls per1000
bed separations in a month.
Conclusion
Patient quality and safety indicators are fundamental facets of finding out whether the
healthcare profession meets minimum patient safety and quality standards. Patients have a right
to access health care that is not only of high quality but also that assure safety to patients. Patient
falls have been deduced by empirical research to be not only detrimental in curtailing patient
health outcomes but also can lead to death. To this end, healthcare institutions and practitioners
ought to put in place formidable policies, and strategies to curtail the effects of falls and
associated injuries. The Plan-Do-Study-Act (PDSA) quality cycles framework can come in
handy in realizing improvements to patient quality and safety by curtailing patient falls.

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 15
References
Agency for Healthcare Research and Quality (2013). Preventing Falls in Hospitals. Available
from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html
Agency for Healthcare Research and Quality (2018). Preventing Falls in Hospitals How do you

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 16
measure fall rates and fall prevention practices? Available from
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html
Australian Institute of Health and Welfare (2017). Admitted patient care 2015–16: Australian
hospital statistics. Health services series no.75. Cat. no. HSE 185. Canberra: AIHW.
Available from https://www.aihw.gov.au/getmedia/3e1d7d7e-26d9-44fb-8549-
aa30ccff100a/20742.pdf
Australian Institute of Health and Welfare (2014). Australian Hospital Statistics 2012-13.
Available from https://www.aihw.gov.au/reports/hospitals/australian-hospital-statistics-
2012-13/contents/table-of-contents.
Australian Commission on Safety and Quality in Health Care (2012). Standard 10 Preventing
Falls and Harm from Falls; Safety and Quality Improvement Guide. Available from
https://www.safetyandquality.gov.au/wpcontent/uploads/2012/10/
Standard10_Oct_2012_WEB.pdf
American Nurses Association. (2005). National database of nursing quality indicators:
Guidelines for data collection and submission on quarterly indicators. Kansas City, KS.
Ambutas, S. (2017). Continuous Quality Improvement. Fall Reduction and Injury Prevention
Toolkit: Implementation on Two Medical-Surgical Units. Medsurg Nursing,
26(3).pp.175-197.
Agostini, J. V., Baker, D. I., Inouye, R. S. K., & Bogardus Jr, S. T. (2001). Prevention of
Delirium in Older Hospitalized Patients. Making Health Care Safer: A Critical Analysis
of Patient Safety Practices, 307.
Curnock, E., Ferguson, J., McKay, J., & Bowie, P. (2012). Healthcare improvement and rapid
PDSA cycles of change: a realist synthesis of the literature. NHS Education for Scotland

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 17
Coutinho, E. S. F., Bloch, K. V., & Coeli, C. M. (2012). One-year mortality among elderly
people after hospitalization due to fall-related fractures: comparison with a control group
of matched elderly. Cadernos de sauce publica, 28, 801-805.
Dunne, T. J., Gaboury, I., & Ashe, M. C. (2014). Falls in hospital increase length of stay
regardless of degree of harm. Journal of evaluation in clinical practice, 20(4), 396-400.
Galbraith, J. G., Butler, J. S., Memon, A. R., Dolan, M. A., & Harty, J. A. (2011). Cost analysis
of a falls-prevention program in an orthopedic setting. Clinical Orthopaedics and Related
Research 469(12), 3462-3468.
Healey, F., Lowe, D., Darowski, A., Windsor, J., Treml, J., Byrne, L., ... & Phipps, J. (2013).
Falls prevention in hospitals and mental health units: an extended evaluation of the
FallSafe quality improvement project. Age and aging, 43(4), 484-491.
Healey, F., & Darowski, A. (2012). Older patients and falls in hospital. Clinical Risk, 18(5), 170-
176.
Haines, T. P., Hill, A. M., Hill, K. D., Brauer, S. G., Hoffmann, T., Etherton-Beer, C., &
McPhail, S. M. (2013). Cost effectiveness of patient education for the prevention of falls
in hospital: economic evaluation from a randomized controlled trial. BMC medicine,
11(1), 135.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2015). Sentinel
Event Alert; Preventing falls and fall-related injuries in health care facilities. Available
from https://www.jointcommission.org/assets/1/18/SEA_55.pdf
McLoughlin, V., Millar, J., Mattke, S., Franca, M., Jonsson, P. M., Somekh, D., & Bates, D.
(2006). Selecting indicators for patient safety at the health system level in OECD
countries. International Journal for quality in health care, 18(suppl_1), 14-20.

PATIENT QUALITY AND SAFETY INDICATORS: PATIENT FALLS 18
NHS National Reporting and Learning System (2015). National Reporting and Learning System
Quarterly Workbook to June 2015. Available from
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=135508.
Rheaume, J., & Fruh, S. (2015). Retrospective case reviews of adult inpatient falls in the acute
care setting. MedSurg Nursing, 24(5), 318.
Siriwardena, A. N., & Gillam, S. (2014). Evaluating improvement. Quality in primary care,
22(2).
Sammer, C. E., Lykens, K., Singh, K. P., Mains, D. A., & Lackan, N. A. (2010). What is patient
safety culture? A review of the literature. Journal of Nursing Scholarship, 42(2), 156-
165.
Varkey, P., Sathananthan, A., Scheifer, A., Bhagra, S., Fujiyoshi, A., Tom, A., & Murad, M. H.
(2009). Using quality-improvement techniques to enhance patient education and
counseling of diagnosis and management. Quality in primary care, 17(3).
Wong, C. A., Recktenwald, A. J., Jones, M. L., Waterman, B. M., Bollini, M. L., & Dunagan, W.
C. (2011). The cost of serious fall-related injuries at three Midwestern hospitals. The
Joint Commission Journal on Quality and Patient Safety, 37(2), 81-87.