Enhancing Quality and Safety Essay

Consider the hospital-acquired conditions that are not reimbursed under Medicare/Medicaid, some of which are specific safety issues such as infections, falls, medication errors, and other concerns that could have been prevented or alleviated with the use of evidence-based guidelines. Enhancing Quality and Safety Essay

Choose a specific condition of interest (Please use patient falls) and incorporate evidence-based strategies to support communication and ensure safe and effective care.
The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote safety in the context of your chosen health care setting.

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 that you know what is needed for a distinguished score. Enhancing Quality and Safety Essay


Explain factors leading to a specific patient-safety risk.
Explain evidence-based and best-practice solutions to improve patient safety related to a specific patient-safety risk and reduce costs.
Explain how nurses can help coordinate care to increase patient safety and reduce costs.
Identify stakeholders with whom nurses would coordinate to drive safety enhancements.
Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style.

Enhancing Quality and Safety

Fall Prevention Program among Inpatients


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.

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, cardiovascular disorders, 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.

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

Fall prevention interventions demonstrated to be effective in lowering the fall rate among 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).

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.

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. Enhancing Quality and Safety Essay


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.


Belcher, J. M. (2020). Quality Initiative to Reduce Falls in an Acute Care Setting. Walden University.

Izumi, S., Barfield, P. A., Basin, B., Mood, L., Neunzert, C., Tadesse, R., … & Tanner, C. A. (2018). Care coordination: Identifying and connecting the most appropriate care to the patients. Research in nursing & health, 41(1), 49-56.

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.

Lee, Y. S., Choi, E. J., Kim, Y. H., & Park, H. A. (2019). Factors Influencing Falls in High-and Low-Risk Patients in a Tertiary Hospital in Korea. Journal of patient safety, 1(1).

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).

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. https://doi.org/10.1097/NNA.0000000000000101.

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. https://doi.org/10.1002/nop2.165.

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. https://doi.org/10.1136/bmjopen-2017-017864.

Vitor A, Moura L, Fernandes L, Botarelli FR, Araújo J & Vitorino I. (2015). Risk for falls in patients in the postoperative period. Cogitare Enferm, 20(1), 29–37.

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.

Enhancing Quality and Safety Essay

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