Critical appraisal of an incident that affected patient safety
Critical incidents and events have significant physical, psychological, financial and social implications for patients. Majority of critical events are however preventable. An incident whereby an elderly patient fell and suffered a hip fracture will be assessed critically. The patient was an 88 year old lady admitted into the nursing home because she had a history of dementia, hypertension, diabetes and hip fracture. She fell during a shift change over when the nurse caring for her was busy and hence did not respond to her calls for assistance in getting to the toilet. The nurse mentioned in her report that the patient needed help in moving around hence she said that the nurses taking over should attend to the patient after the report. The patient detested being independent on others hence when no one came to her assistance she decided to go to the bathroom by herself. However, the wheelchair was not locked properly, the fluorescent lighting in the room was dim hence she could not see clearly and the floor was very smooth so when she tried to support herself on the wheelchair, it moved and she slide and fell fracturing her left hip in the process. The patient had suffered a fracture on the same hip one year prior to the incident.
Body
1. Was the nurse confident in his/her reasoning? 1
2. Was the whole situation (relationships, background, environment) taken into consideration? 1
3. Was there adequate consideration of alternatives, even those that were nontraditional or creative? 1
4. Was the nurse flexible enough? 1
5. Was the nurse engaged enough to really want to understand fully? 0
6. Were decisions based on usual practice and/or bias, or was the turth sought even if it went
contrary to usual practice? 1
7. Were there any intuitive signs of this happening? 1
8. Were all views considered? (The field was not narrowed too quickly) 1
9. Did the nurse keep trying to solve the problem? (Didn’t give up too quickly.) 1
10. Was there evidence of anyone standing back and reflecting on what was happening? 0
11. Was there evidence of the nurse breaking the situation down to better understand what
was happening? 1
12. Were applicable standards upheld? 1
13. Were similarities of differences among parts of the issues distinguished carefully? 1
14. Was all the possible information gathered? 1
15. Was there adequate evidence to support the conclusions drawn? 0
16. Was there evidence that this incident could have been predicted? 2
17. Was knowledge applied well in this situation? 1
The total score for the assessment is 14 interpreted to mean that insufficient critical thinking probably contributed to the event.
As the manager of the unit, to prevent future fall incidents, I would through collaboration with others implement single and multifaceted measures for the prevention of such falls. Firstly, I would ensure that during shift change-overs when nurses are handing over their report, someone is available to attend to the patients (Hill et al., 2009). This would necessitate increasing the number of staff available during shift change-overs. Additionally, I would ensure that a risk for fall assessment is done using an appropriate tool for every patient who is admitted to the unit. The tool to be used would incorporate risk factors for falling such as cognitive deficits like poor judgment that occur secondary to conditions like dementia, general body and muscle weakness, poor eyesight, personality factors such as stubbornness, history of previous falls, neuromuscular conditions amongst others. For instance, patients with a history of a hip fracture in the preceding one year are at increased risk of recurrence of the same (Al-Aama, 2011) and since the patient in this incident had a history of previous fall that resulted in a fracture, a risk for fall assessment during admission would have red flagged that this patient needed extra attention. This would ensure that patients at risk for falling are identified early and preventive measures adopted. I would also advice the hospital management on the need for ensuring environmental safety more so considering that environmental factors contribute to the risk for falls. For instance, poor lighting, slippery floors, limited space and malfunctioning instruments are some of the environmental factors that increase the risk of falls amongst the elderly (Hill et al., 2009). On the other hand, polypharmacy amongst the elderly also contributes to increased risk for falls. The patient in this particular case was on more than six drugs as of the time of the incident some of which were not really necessary hence I would advocate for regular reviews of patient medications. Achievement of the latter would require increased teamwork between nurses caring for the patients and the attending physicians (Gadsby, Galloway, Barker, & Sinclair, 2011). Training on polypharmacy especially the adverse effects of it for both nurses would therefore come in handy if this goal is to be realized. It would therefore be necessary to convince the hospital administration on the importance of investing in such training.
Conclusion
In conclusion thus, falls amongst the elderly are quite common and this case was just one in many. The factors that contribute to this falls encompass personal, environmental factors and an interaction of the two. By implementing single and multi-component interventions at the institutional level such as assessment tools that promote critical thinking on the patients risk for fall and identification, planning and adoption of suitable prevention measures, these kinds of falls may be prevented and their adverse effects averted.
References
Al-Aama, T. (2011). Falls in the elderly: Spectrum and prevention. Can Fam Physician, 57(7),
771-776.
Gadsby, R., Galloway, M., Barker, P., & Sinclair, A. (2011). Prescribed medicine for elderly
frail people with diabetes resident in nursing homes-issues of polypharmacy and
medication costs. Diabetic Medicine, 29, 131-139.
Hill, E.E., Nguyen, T.H., Shaha, M., Wenzel, J.A., Deforge, B.R.,& Spellbring, A.M. (2009).
Person-environment interactions contributing to nursing home resident falls. Res
Gerontol Nurs., 2 (4), 287-296.
