Advance Professional Roles and Values Project
Falls

Keri Cochran
October 20, 2014
Western Governor’s University

The problem and explanation: The hospital I am employed at is currently having an issues with patient falls. The hospital is a “no restraint facility” and strongly discourages the use of any form of restraint including leather, soft, posey vests, or chemical. Currently the line of defense is using staff sitters, moving the patient to a visible room when available and or family members are encouraged to come and stay with their loved ones who are at high risk of falls. This does not always rectify the issues secondary to staffing issues and family participation.
The facility has had two critical falls this year, one …show more content…

I looked at the demographic of the population and most were post op angiogram patient who had had an intervention of some sort ie. Cardiac stent placement, angioplasty, pacemaker / AICD placement. All of which receive narcotics along with Versed, a hypnotic. The patients come to the unit and most need to be flat from anywhere from 4-8 hours depending on procedure and closure devise used. The protocol is for the patient to receive orthostatic vitals prior to ambulation for the first time. This is made very clear to the patient upon admitting to the floor and reiterated frequently during the recovery phase. When looking at the medication administration record every patient that experienced a fall had narcotics and usually a sleeping medication or antianxiety was noted as given between 2000-2200hrs. This was disturbing because older folks should not be given particular combinations of medications especially when they are not use to taking them on a regular basis. This sent up some red flags. We now needed to look at medication usage as well as patient getting tangled up in IV tubing, pumps, cord, poles, as well as the telemetry boxes and changers which were plugged into the walls behind the bed. Initially we assumed the issues were the telemetry boxes and chargers and the IV equipment but after investigation noticed a huge issue with medication administration and the questions became did medications play a