Enhancing Quality and Safety.

Posted: November 3rd, 2022

Enhancing Quality and Safety.


For this assessment, you will develop an online resource repository of at least 12 annotated professional or scholarly resources that you consider critical for the audience of your safety improvement plan to understand or implement to ensure the success of the plan. By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: •Competency 1: Analyze the elements of a successful quality improvement initiative. ◦Analyze the usefulness of resources to role group responsible for implementing quality and safety improvements. •Competency 2: Analyze factors that lead to patient safety risks.Enhancing Quality and Safety.


◦Analyze the value of resources to reduce patient safety risk or improve quality. •Competency 3: Identify organizational interventions to promote patient safety. ◦Identify necessary resources to support the implementation and sustainability of a safety improvement initiative. •Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. ◦Present compelling reasons and relevant situations for resource tool kit to be used by its target audience. ◦Communicate in a clear, logically structured, and professional manner, using current APA style and formatting. 1.Build on the work done in your first three assessments and create an online tool kit or resource repository that will help the audience of your in-service understand the research behind your safety improvement plan and put the plan into action. Enhancing Quality and Safety. assemble an online resource tool kit containing at least 12 annotated resources that you consider critical to the success of your safety improvement initiative. These resources should enable nurses and others to implement and maintain the safety improvement you have developed. It is recommended that you focus on the 3 or 4 most critical categories or themes with respect to your safety improvement initiative. For example, if your initiative concerns improving workplace safety for practitioners, you might choose broad themes such as general organizational safety and quality best practices; environmental safety and quality risks; individual strategies to improve personal and team safety; and process best practices for reporting and improving environmental safety issues.Enhancing Quality and Safety. Following the recommended scheme, you would collect 3 resources on average for each of the 4 categories. Each resource listing should include the following: •An APA-formatted citation of the resource with a working link. •A description of the information, skills, or tools provided by the resource. •A brief explanation of how the resource can help nurses better understand or implement the safety improvement initiative. •A description of how nurses can use this resource and when its use may be appropriate. Here is an example entry: •Merret, A., Thomas, P., Stephens, A., Moghabghab, R., & Gruneir, M. (2011). A collaborative approach to fall prevention. Canadian Nurse, 107(8), 24–29. Retrieved from www.canadian-nurse.com/articles/issues/2011/october-2011/a-collaborative-ap ◦This article presents the Geriatric Emergency Management-Falls Intervention Team (GEM-FIT) project. It shows how a collaborative nurse lead project can be implemented and used to improve collaboration and interdisciplinary teamwork, as well as improve the delivery of health care services. This resource is likely more useful to nurses as a resource for strategies and models for assembling and participating in an interdisciplinary team than for specific fall-prevention strategies. It is suggested that this resource be reviewed prior to creating an interdisciplinary team for a collaborative project in a health care setting. Additionally, be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so you understand what is needed for a distinguished score. •Identify necessary resources to support the implementation and continued sustainability of a safety improvement initiative. •Analyze the usefulness of resources to the role group responsible for implementing quality and safety improvements. •Analyze the value of resources to reduce patient safety risk. •Present compelling reasons and relevant situations for use of resource tool kit by its target audience. •Communicate in a clear, logically structured, and professional manner that applies current APA style and formatting.Enhancing Quality and Safety.

Improvement Plan Tool Kit

Gu, Y. Y., Balcaen, K., Ni, Y., Ampe, J., &Goffin, J. (2016). Review on prevention of falls in hospital settings. Chinese Nursing Research, 3(1), 7-10.

Retrieved from https://www.sciencedirect.com/science/article/pii/S2095771816300202

The article provides a review of the main causes of falls, preventative measures against falls, and the bestpractices of fall prevention. According to the article, causes of falls are multifactorial, and therefore fall preventative measures should be comprehensive. The management, nurse leaders, and other nursing staff should ensure that the fall prevention strategies are tailored to the needs of a specific healthcare organization, and there are continuous improvement interventions. This resource can be useful when implementing a culture of safety in a healthcare organization to reduce falls.


Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2019). Educating hospital patients to prevent falls: protocol for a scoping review. BMJ Open, 9(9), e030952. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756445/

This article provides a review of patient education programs that encourage engagement and enable inpatients to understand their increased risk for falls. It indicates the importance of patient education in preventing falls among high-risk patients. This resource will help nurses to be aware of the appropriate educational strategies effective in making patients understand their heightened risk of falls. It is recommended that the resource be used when developing patient educational programs regarding falls.Enhancing Quality and Safety.


Howland, J., Hackman, H., Taylor, A., O’Hara, K., Liu, J., &Brusch, J. (2018). Older adult fall prevention practices among primary care providers at accountable care organizations: A pilot study. PloS one, 13(10).

Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205279

According to the article, there is a need for healthcare providers, and particularly nurses to engage in continuous education and training about the effective fall prevention strategies. This will ensure that healthcare workers are up-to-date about fall prevention interventions. Nurse leaders and organizational leaders can use this resource to emphasize the need for nurses engaging in research and training as well as in developing educational programs on fall prevention.Enhancing Quality and Safety.


Mata L. Cissa A, Gabrielle P &Moraes T. (2017). Factors associated with the risk of falls in adults in the postoperative period: a cross-sectional study. Rev Lat Am Enfermagem. 25(2904). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5492651/

The article provides information about the factors that increase the risk of falls for patients who undergo surgical procedures. The article also provides the strategies effective in reducing the risk of falls among surgical patients. This resource will help nurses and the interdisciplinary team involved in the care of surgical patients of the risks of falls and the appropriate strategies to implement to lower the risk of falls for surgical patients. It is recommended that the resource be used to support and inform the planning of nursing actions developed to prevent the risk of falls during the postoperative period.Enhancing Quality and Safety.

Mitchell, M. D., Lavenberg, J. G., Trotta, R. L., &Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: a systematic review. The Journal of nursing administration, 44(9), 462–472.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547690/

This article provides a review of evidence regarding the effectiveness of hourly rounding programs in improving nursing care and patient satisfaction as well. According to the article, hourly rounding programs can be effective in improving nursing care and thus preventing risks such as the risk for falls. This resource will be useful to nurses and nurse leaders by informing them about the importance of hourly rounding programs in improving the responsiveness of nurses and reducing the risk of falls. Nurse administrators and nurse leaders can use the resource during the implementation of the quality improvement initiatives such as fall prevention programs.Enhancing Quality and Safety.


Morris, R., &O’Riordan, S. (2017). Prevention of falls in the hospital. Clinical medicine (London, England), 17(4), 360–362. https://doi.org/10.7861/clinmedicine.17-4-360.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297656/

The article sought to investigate the risk factors for falls and how falls can be prevented. According to the article, a multidisciplinary approach is the most effective way of mitigating risk for falls and ensuring a holistic approach to preventing falls. This article provides the best practice in fall prevention. The management, trust board, and the clinical staff can use the resource to identify the causes of falls in healthcare organizations and implement the necessary initiatives to mitigate the risk for falls.Enhancing Quality and Safety.


Muray, M., Bélanger, C. H., &Razmak, J. (2018). Fall prevention strategy in an emergency department. International journal of health care quality assurance, 31(1), 2-9. Retrieved from https://www.researchgate.net/publication/322689007_Fall_prevention_strategy_in_an_emergency_department

The article provides information about the importance of using fall prevention strategies to prevent patient harm and also save organizational resources because falls are associated with injuries and increased healthcare costs. According to the article, precautionary measures are particularly important to patients with susceptible physical and cognitive conditions to prevent falls. The clinical managers can use this resource to communicate and inform the need for implementing fall prevention measures among the nursing staff. The resource is recommended when implementing quality improvement initiatives in healthcare organizations.


Ott L. D. (2018). The impact of implementing a fall prevention educational session for community-dwelling physical therapy patients. Nursing Open, 5(4), 567–574.

Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1002/nop2.165

The article sought to investigate the effect of a fall prevention educational program and fall prevention interventions to reduce the rate of falls among older adults. The resource will be useful to the nurses and particularly community health/public health nurses to guide their conversations regarding fall within the community. Education can improve awareness about falls and thus reduce the risk of falls. The resource can be useful during the implementation of fall prevention strategies among older adults, inpatients, and in the community-dwelling as well.Enhancing Quality and Safety.


Slade, S. C., Carey, D. L., Hill, A. M., & Morris, M. E. (2017). Effects of falls prevention interventions on fall outcomes for hospitalized adults: protocol for a systematic review with meta-analysis. BMJ Open, 7(11), e017864.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5695509/

The article provides information about the fall prevention interventions in adult inpatients and the elements of effective fall prevention strategies. The article identifies how healthcare providers can integrate evidence-based practice, environmental modifications, and self-management initiatives when designing fall prevention strategies. Nurses can use the resource to inform fall risk assessment procedures and also to formulate educational programs aimed to prevent falls.


Toren, O., &Lipschuetz, M. (2017). Fall prevention in hospitals-the the need for a new approach to an integrative article. Nurse Care Open Acces J, 2(3), 93-96. Retrieved from https://medcraveonline.com/NCOAJ/falls-prevention-in-hospitals-the-need-for-a-new-approach-an-integrative-article.html

According to the article, effective fall prevention strategies should integrate components such as patient engagement, personalize fall prevention interventions and examine the ability and will of the patients to engage in the required behaviors and actions to prevent falls. The resource shows how customizing and personalizing fall prevention strategies can improve their efficacy. This resource is useful to the multidisciplinary team involved in fall prevention programs within healthcare organizations. It is highly recommended for the review of this article during the design of any quality improvement program.Enhancing Quality and Safety.


Vitor A, Moura L, Fernandes L, Botarelli FR, Araújo J & Vitorino I. (2015). Risk for falls in patients in the postoperative period. CogitareEnferm,20(1), 29–37. Retrieved from file:///C:/Users/user/Downloads/389dcbd0ed573ac649ba3de9af4ef4596112.pdf

The article provides information about the major risk factors for falls for patients during the postoperative period. The article providers information on how the risk factors for falls among surgical patients can be reduced. This resource will help nurses and the interdisciplinary team involved in the care of surgical patients of the risks of falls and the appropriate strategies to implement to lower the risk of falls for surgical patients. The resource can be used to inform and support the formulation of nursing actions aimed to prevent or reduce the risk of falls during the postoperative period.


Vonnes, C., & Wolf, D. (2017). Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. BMJ open quality, 6(2), e000038. https://doi.org/10.1136/bmjoq-2017-000038. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699193/

The article provides information about the significance of engaging patients and their families and the need for a collaborative approach in approaches aimed to prevent falls during hospitalization. According to the article, involving patients and their families during care planning can significantly reduce the patients’ risk for falls. The resource will help nurses and other healthcare providers involved in fall prevention strategies in healthcare organizations. Nurses can use the resource to support collaborative communication and discussions allied to fall prevention. This resource can serve as a resource when developing comprehensive safety programs by ensuring that patients and their partners are partners in fall prevention strategies.


Patient falls and the resulting injuries have adverse effects on the physical, mental, and social health of the patients. Adverse effects of patient fall include injuries, possible deaths, fractures, prolonged periods of hospital stay, and increased healthcare costs (Mata et al., 2017). Patient falls can also cause trauma, reduce the quality of life, and the ability of an individual to carry out activities of daily living. This emphasizes the importance of preventing patient falls.Enhancing Quality and Safety.

Factors leading to Patient Falls

Factors attributable to inpatient falls include the clinical conditions, impairments like muscle weakness and poor vision, poor gait, history of fall, sedation medications, and patients not asking for help when getting out of the bed (Mata et al., 2017). Some conditions such as hypoxia, delirium, impaired cognition, cardiovasculardisorders, cancer as well as conditions likely to affect gait, balance, and sight increase the risk of a patient sustaining falls. Additionally, medical procedures such as surgery have been demonstrated to increase the risk of falls among patients. Medications such as anti-hypertensives and sedatives have also been shown to elevate the fall risk among patients (Mata et al., 2017).

Environmental factors such as the unsuitable design of the patient’s room, poor lighting, and long-distance between the patient’s bed and the lavatory are also associated with increased risk for patient falls. Moreover, the fact that patients are not familiar with the hospital environment and varying locations of light switches and facilities such as toilets may lead to confusion for patients and increase the risk of falls (Vitor et al, 2015). Poor communication is also a major contributing factor to patient falls. Poor nurse-patient relationships as well as poor inter-professional relationships contribute to falls. A study conducted by Vitor et al (2015) indicated that communication failures during care transition and handoffs contribute to patient falls. Similarly, poor communication and therapeutic relationships contribute to falls where patients may for example fail to seek help when moving or communicate any aspect that affects their mobility of vision.Enhancing Quality and Safety.

Evidence-Based &Best-Practice Solutions to Prevent Patient Falls

Fall prevention interventions demonstrated to be effective in lowering the fall rateamong patients include comprehensive fall risk assessment, patient education, and hourly rounding.

Assessment of patients at risk of falls is important in preventing falls. There are various fall risk assessment tools useful in assessing the patient’s risk for falls. A fall risk assessment helps in identifying patients at high risk of falls and this facilitates the implementation of the recommended strategies to reduce the risk fall and ensuring injuries or prevent falls (Slade et al., 2017).Enhancing Quality and Safety.

Patient education enables patients to understand their increased risk for falls and also promotes a collaborative and engaging approach towards preventing falls (Heng et al., 2019). During education, patients are educated to wait for assistance or call the nursing staff before getting up, always turn on the light, being cautious after taking sedatives, always wear vision aids when necessary, and move slowly (Ott., 2018). These are factors that may reduce the patient’s risk of falls and thus educating patients about them will prevent falls.

Hourly rounding is an effective intervetion to prevent patient falls. Hourly rounding is the purposeful rounding performed after every one-hour to assess the care activities for patients (Mitchell et al., 2014). During hourly rounding, the patient’s personal needs are assessed as well as the risk for falls and pain level, repositioning of the patient, facilitate access to the essential needs for the patient. Therefore, hourly rounding reduces the risk of falls by ensuring that aspects that may lead to risk movement for the patient are addressed and also their risk for falls.Enhancing Quality and Safety.

How Nurses can Help Care Coordination

Care coordinators involve the deliberate organization of the care activities of patients and information sharing among all the stakeholders involved in the patient’s care to attain more effective and safe care (Izumi et al., 2018). Regarding patient falls, a nurse can assess the needs and preferences of the patient and communicate the information to the right individuals promptly. This information is then used to provide the appropriate, safe, and effective care to the patient (Izumi et al., 2018). For example, when after the fall risk assessment, the nurse communicates the to the physician that some medications are making the patient very drowsy and increasing the fall risk, the physician will be able to prescribe an alternative medication with minimal side effects.


The key stakeholders that the nurse should coordinate with during the implementation of the fall prevention program include the physician, pharmacy, rehabilitation specialist, and quality improvement specialists (Belcher, 2020). Physicians have numerous roles such as reviewing the patient’s medication to check if the medication increases the fall risk and examining the health condition that could increase fall risk. The pharmacy has the role of reviewing the organizational formulary to establish if some medications should be limited in patients at risk for falls while the rehabilitation specialist has the role of prescribing the appropriate occupational and physical therapy or suggesting the required assistive devices such as wheelchairs or walkers and the appropriate activity levels for patients. The quality improvement specialists will provide help to the team implementing the fall prevention program (Belcher, 2020).


A fall prevention program was selected to improve quality and safety. Factors contributing to inpatient falls include the clinical conditions, impairments like muscle weakness and poor vision, poor gait, history of falls, sedation medications, and environmental factors, poor communication, and lack of patient awareness. Evidence-based fall prevention strategies include comprehensive fall risk assessment, patient education, and hourly rounding.Enhancing Quality and Safety.



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