Read two or more of your colleagues’ postings from the Discussion question. Respond to at least two of your classmates. As a member of a community of practice, help each other refine and clarify the

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Read two or more of your colleagues’ postings from the Discussion question.

Respond to at least two of your classmates. As a member of a community of practice, help each other refine and clarify the patient-centered Practice Experience Project. Provide support and suggestions on the importance of the practice problem in improving patient outcomes.


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The patient-centered practice problem chosen for our practice setting is falls. According to the World Health Organization, falls are the second leading cause of unintentional deaths worldwide, with age being a significant factor. A fall is an occurrence in which a person comes in contact with the floor at any time, even if it is inadvertent or not (World Health Organization, 2021). If a patient slides down to the floor or their knees buckle and are assisted to the floor, it is still considered a fall in the healthcare setting. Therefore, any fall has to be reviewed and reported bringing attention to further preventing them from occurring.

Falls that occur in the hospice unit are integrated with the data of Mercy Regional Medical Center. In my patient setting, we are at a greater risk of falls due to the use of high-risk medications, increased altered mental status due to disease progression, oversized rooms that take longer to get to, and encouragement of independence. Based on information from the Power Business Intelligence or Power BI application, falls are still of concern. There is a high enough incidence rate in our hospital that placement of a new call light system has begun facility-wide to alert more staff of patient needs and reduce patient fall risk behavior. Currently, the number one factor contributing to falls is either elimination-related or ambulatory needs. Based on the information read, more falls occur between the times of 0700-1700. The data is contrary to what one might think, with more individuals available to help during the day versus night shift. Regardless of the amount of staff on hand, falls are still occurring regularly.

There are numerous possibilities to review in how to improve the patient experience and prevent falls. For example, analyzing a fall and whether or not the level of care deviated from what is safe. Was an equipment malfunction discovered, or are patients getting rescored after being given high-risk medications? These are just a few questions in thinking about ways to analyze potential safety improvements in inpatient care. Increasing staff awareness or implementing changes to reduce fall risk expresses a dedication and commitment to improving the patient experience and quality patient care.

After discussing the various possibilities for this practice problem with my clinical leader, fall risk was selected based on the extent of information available and the fact that it continues to be an area of need in quality improvement for patient care and safety. Falls are considered the most common adverse event in hospitals, with a range of 7000,000 to 1 million falls yearly. In addition, the Centers for Medicare and Medicaid Services discontinued reimbursement for hospital-related falls, thus causing more pressure on facilities to prevent the sentinel events due to financial burdens (LaLaurin & Shorr, 2019). If we continue to work on the value of quality as an organization, it will behoove us to continue to address this sentinel event.

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