There has been a sharp increase in the number of falls on your…  There has been a sharp i

There has been a sharp increase in the number of falls on your…  There has been a sharp increase in the number of falls on your unit. Last year there were 2 in a 1 year period. This year there have been 3 over the last 3 months. During this same time period there were several staff transfers out of your unit and the positions have not been filled due to a hiring freeze. You are dealing with what could be called chronic understaffing, staff working double shifts, and low morale. The float personnel who are sent to your unit have not been implementing the existing fall risk assessment protocol when they admit a patient. A spot check of your charts show that 50% of the patients on your unit have not had a standard fall risk assessment done on admission. When you go to find the tool or form that is used for the assessment you can find no forms.Next, you look at the facts involving an individual patient who fell on your unit. Mrs. Nguyen is an 85 year old non English speaking patient who was admitted because of a transient ischemic attack and to rule out a stroke. She was in for observation and diagnostic testing. She got up to go to the bathroom. Since it was 2 a.m. apparently all the lights were out in the room. She tripped over a wheelchair that had been used earlier in the day to take her to interventional radiology.Using the fishbone diagram provided in this link/content/enforced/856375-NSG_330_201_1085/Fishbone diagram1.docx fill in the problem statement and the causes that you identify.Attach your diagram to the discussion board.Answer the following questions:What contributory causes did you identify?Where did you place on the fishbone diagram such things as lack of staff, overworked staff, lighting conditions, the absence of a bed alarm, not following basic safety practices, the absence of fall risk assessments being done, the absence of fall risk assessment forms, the lack of availability of basic safety equipment (i.e. a walker), etc.Can all of the causes that you identified be placed somewhere on the fishbone diagram?Can you add other bones to the fishbone?Does it matter if a cause is shown in more than one area?If you were going to do an in-service to bring the attention of the staff to this problem, what data and information would you use and how would you display it?Would it be helpful to analyze the other two recent cases on your unit where the patients fell. Why or why not?Choose one intervention that might make an impact immediately and one long term?How could nursing use technology to prevent future falls or identify risks for falls? Be creative!                          Health Science Science Nursing NSG 330 Share QuestionEmailCopy link Comments (0)

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