I interviewed James Alviar RN, the Coordinator of Risk Management at my current place of employment the Queen’s Medical Center West Oahu. I asked him if there were any current risk management issues at our facility that we could discuss, but he said all current issues were confidential and he could not divulge any information to me. Instead, James pointed me in the generic direction of hospital falls that is a nationwide risk management issue and also pertains to us at Queens Medical Center. This paper will be discussing risk management’s role, what falls are, how falls are addressed, how risk management would remedy the problem, and how the similar situation is discussed at another facility. Queen’s Health Systems Risk Management (Risk Management) serves the Queen’s Health Systems (QHS) by developing and applying an integrated program for the preservation of QHS’s capital assets and resources.
The role of the Risk Management Department is to plan, direct, and coordinate the risk management and insurance function of Queen’s Medical Center, subject to and consistent with the Queen’s Health Services Mission Statement, policy and procedures, guidelines and applicable laws. Risk management is a process with four major components: identification, assessment, mitigation, and monitoring. Risk management addresses many issues that include patient safety, potential medical questions or errors, federal regulations, and legislation impacting healthcare. At Queen’s Medical Center, there are two options to file an event report. The employee may submit an event report anonymously or log onto the hospital intranet and utilize the RL’s Risk Management software.
The software is an easy step by step program for writing a thorough incident report to be submitted to Risk Management. The purpose of the occurrence report is to: Assist in identifying potential liability issues, facilitating appropriate corrective or remedial measures. To develop only information for investigation, evaluation, and a final disposition of the reported incident. The information collected will provide management with a means of analyzing risk and quality levels. Fulfill QHS’s internal reporting requirements, regulatory requirements, or insurance carrier’s requirements or legal obligation.
Once the Risk Management department gets the report, they determine whether the situation should be investigated. If the situation needs to be examined, other departments are called upon to review the case. The other departments are but not exclusive to Falls Prevention and Protection Committee/Patient Safety, Department Managers and their nurses, Risk Managers, Human Resources, and Patient Advocate. Follow-up reports will be completed within three weeks, unless circumstances require a quicker response. I visited a smaller 57-bed hospital located central on the island to serving the residents of Central Oahu and the North Shore. Their incident reports are submitted on a form requiring the following information: How, when (date and time) and where the incident or offense took place The names of any injured persons and witnesses
The nature and location of any injury or damage arising out of the incident or offense If a security report was made, a forwarded copy is required. If an incident report is written up, it would be submitted to the Risk Management where it would be reviewed. An investigation begins with a meeting with the department manager of the unit where the event occurred. If the incident was a fall, the incident is investigated to see if the ultimate cause of the fall was physiological or environmental. If the patient fell for physiological reasons, a plan of care is initiated. If it were an environmental reason like a loose handrail, they would be repaired immediately. Specifically to this paper, we will focus on patient falls.
Patient falls are ubiquitous. According to the “American College Of Surgeons National Trauma Data Bank 2013 Annual Report” (2013), the highest mechanism of injury by region are falls with a total of 338,805 reported cases and with the second highest mechanism of injury from motor vehicle injury at a total of 234,164 reported cases. A patient’s fall is an unintended descend to the floor that may or may not result in any injury to the patient. A fall is when a patient lands on a surface where you would not expect to find the patient. There are many risk factors associated with falls such as: Physiological reasons (changes in blood pressure, Parkinson’s, arthritis, neuropathy, vision problems ) Environmental reasons (wet floor, rugs without non-skid backing, poor lighting)
Adverse effects of medications
An assisted fall is when a staff member witnesses a patient’s fall and attempts to minimize the impact of descend. Many patient falls occurring during hospital encounters may cause little or no harm but some can result in serious and even possibly life-threatening consequences for many patients such as hip fractures and head trauma. Even when a fall does not lead to death, it can require prolonged hospitalization. Some could suffer disability, loss of function, and lose their independence or premature death. “Patient falls in hospitals are a common and often preventable adverse event. Nurses routinely conduct fall risk assessment on all patients, but communication of fall risk status and tailored interventions to prevent falls is variable at best.” (Hurley, Dykes, & Carroll, 2009). When reporting a fall, the event report should be submitted as soon as possible after the event is discovered. The employee who is involved or observes the incident should complete the report.
Although employees can submit an incident report anonymously, submitting through the Risk Management Website in the QMC intranet using the RL’s Risk Management program is preferred. Documentation should be objective, fact-based, and not include personal opinions or subjective information. If a visitor falls or is involved in the incidence, the Security Department should be called to take statements, names, and any necessary evidence, such as photographs. An incidence report should be complete including names of witnesses and any pertinent information. If a visitor is injured, he or she should be encouraged to be treated in the Emergency Department. After submitting the report, Risk Management and the designated managers are notified immediately.
The responsible manager will review all submitted reports, investigate the events as indicated, and institute any necessary corrective action. If it’s indicated, the incident report may be presented to the Performance Improvement Coordinator for analysis. Risk management periodically reports event information to the hospital Patient Safety Committee. These activities are considered quality improvement related and a patient safety work product. The event reports are intended for administration use. If it were a patient here should not be any reference to the incident report in the patient’s medical record. The event, effects on the patient, and action taken must be documented in the medical record for patient care purposes. “Prevention of falls in inpatient settings requires a multidisciplinary, multifaceted approach.
There is not one definitive factor that is the silver bullet in preventing falls. Even though hospitals have devoted quality improvement and research efforts to prevent falls, patient falls consistently compose the largest single category of reported incidents in hospitals.” (Rowe, 2013). It is important that hospitals maintain a safe and effective environment to prevent or limit falls and/or fall-related injuries by patients, visitors, and staff. Departments such as Risk Management, Falls Prevention and Patient Safety, and Patient Advocate were created to help maintain a hospital’s safe, healing environment.
American College of Surgeons National Trauma Data Bank 2013 Annual Report. (2013). Retrieved from https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdb%20annual%20report%202013.ashx Hurley, A., Dykes, P., & Carroll, D. (2009). Fall Tip : validation of icons to communicate fall risk status and tailored interventions to prevent patient falls. Studies in health technology and informatics, 146(), 455-459. University of Phoenix Online Library. Rowe, J. (2013, June). Preventing Patient Falls What are the Factors in Hospital Settings that Help Reduce and Prevent Inpatient Falls?, Home Health Care Management & Practice, 25(3), 98-103. University of Phoenix Online Library
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