The root-cause analysis is one of the most important devices for improving safety and quality in nursing practice. This approach identifies the underlying causes of patient safety issues and is crucial for effective intervention development. Root-cause analysis goes below the superficial ghosts to disclose what initiated all these adverse cases. Through a complete process of identifying the root causes of these issues, irrespective of whether they are procedural inadequacies, environmental factors, human error, or systemic problems, healthcare professionals will be able to treat such causes directly. This methodology also guarantees that solutions are short-term patches and long-term alterations to enhance patient safety. Second, this approach develops an analytical mindset among healthcare professionals that promotes a proactive approach to risk anticipation and management that guarantees ongoing improvement in care delivery. The outlined plan is an attempt to tackle the found root-cause analysis underlying falls in geropsychiatric patients in general, a significant matter, as revealed in an earlier assessment.
In geropsychiatric patients, the institutions of care falls represent a patient safety issue, which, in the majority of instances, leads to severe head injuries and hospitalizations (Pachana et al., 2021). Twenty falls per year were systematically collected and analyzed based on the root-cause analysis of this problem. Emphasized elements involved the issues of impairment as a result of medications, zolpidem as a sedative that leads to immobility and poor balance. Falls were partly linked to the night shifts because of environmental factors such as poor light sources and insufficient staff numbers. The relationship between fall incidence and staffing levels was evident, enabling us to identify a significant attribute regarding patient safety. The majority of falls occur in the area of patients’ beds during evening or night shifts when the number of staff is usually restricted in the majority of healthcare facilities. This development suggests that the inability to be accessible to the staff during these hours can compromise proper patient monitoring and timely help, as geropsychiatric patients need to be monitored frequently and with fast assistance. These changes increase risk because of worse visual acuity, patient disorientation is higher, and evening drugs cause side effects. This leads these observations to rave about the need to look over individual allocation and patient control during night watch to ensure adequate personnel attention management and prompt response so patients can meet immediate needs and reduce the incidence of falls.
Evidence-based strategies for addressing identified causes in solution form. The application of sedatives needs to be explored, and melatonin could replace them as it is unlikely to make the patient oversedated (Cuomo et al. 2021). The electronic bed- and chair-exit alarms can also warn of potential falls. Intentional rounding, a proactive patient care method to prevent falls in geropsychiatric patients, also proves to be quite effective. This practice involves regular, interval rounds by nurses for each patient. Though not just physical assessments, these rounds develop a psychological comprehension of each patient’s needs, including pain management, toileting, and accessibility to their belongings. Intentional rounding aids in identifying fall risk factors early, like harmful environmental threats or changes to the patient’s condition, by organized and regular interactions. In addition, this approach strengthens staff–patient communication and accountable care by building trust. Intentional rounding commonly includes patients handling immediate safety concerns and increasing patient satisfaction and health.
The improvement plan comprises two main strategies: Decreasing performance and cooperation between employees and environmental changes (Helmer-Smith et al., 2022). In addition, intentional rounding and one-to-one patient observation are essential aspects of staff training, particularly regarding high-risk patients. This training allows an individual to guarantee that employees can observe patients adequately and respond fairly quickly to reduce falls. Incorporating ecological changes and specific signage significantly increases the safety levels in geropsychiatric units. The creation of improvements like beta and chair-exit alarms is a very crucial step in minimizing fall threats. Actively preventing falls is achieved through the alteration of the physical setting with staff awareness that allows extending external threats to improve patient mobility and stability. The ideal method would be the signs used to warn all staff members about fall risks. For instance, it is easy to inform caregivers if a patient has a high fall risk with specific symbols or color-coded signs beside the bedside and on their door. This image communication approach assures staff security in all cases where the patients know or do not know. This increased awareness allows prompt attention to possible situations where a patient may fall, greatly enhancing safety.
The successful implementation of this safety improvement plan relies upon the capability to capitalize upon current resources available in the organization. This entails capitalizing on existing capabilities and workforce knowledge to ensure monitoring and enhancement of patient care (Potts et al., 2023). it is possible to make the necessary changes to enable installations of bed- and chair-exit alarms using modern infrastructure. By relying on already having organizational resources for a safety improvement plan, you ensure cost-effectiveness and keep minimizing patient routine disruption as well as staff practice revisions. This strategy also needs more hiring of new staff. Therefore, it means lower financial expenditure due to the fourth factor, which reflects the use of the talents and competencies of current staff for improved patient tracking or learning new procedures.
Alternatively, recycling existing assets, including turning beds and chairs to ensure safety, would involve minimum adjustments in the transition process due to the ease of change and low cost of these available without requiring much money. This way, it preserves patient and employee routines, giving them a familiar feeling. It also encourages staff engagement and loyalty since they involve themselves in improvement using their shared resources. This level of acquaintance reduces the resistance to change and speeds up the pace of adjustment, which increases efficiency and effectiveness in implementing this plan.
Falling incidents among geropsychiatric patients are one of the major safety issues that are preventable. This concern can be adequately handled by conducting a comprehensive root cause analysis and implementing an evidence-based safety improvement plan. The proposed program, which includes staff training, medication management, and environment alteration, is an integrated approach to enhancing patient safety in geropsychiatric environments. The generic approach also provides a safety improvement plan that offers more than the short-term solution of immediate safety considerations as a key component of building an atmosphere that always supports quality nursing practice. The plan promotes an environment suitable for monitoring quality and safety at all times and improving using standardized changes in staff training, medicines control, and infrastructural changes. The proactive strategy ensures that staff remains vigilant and adaptive to the patient’s needs, essentially an ongoing evaluation of self-assessments. Involving the employees in developing and implementing safety measures fosters a feeling of ownership in the patient’s care. This all-encompassing approach ensures that safety is embedded in the nursing practice rather than being a mere merit of compliance. The ongoing refinement by feedback and new standards reinforces the concept of the quality improvement journey as an endless pursuit, not a state of arrival.
Pachana, N. A., Molinari, V., Thompson, L. W., & Gallagher-Thompson, D. (Eds.). (2021). Psychological Assessment and Treatment of Older Adults. Hogrefe Publishing GmbH. https://books.google.com/books?hl=en&lr=&id=YqSbEAAAQBAJ&oi=fnd&pg=PT5&dq=For+geropsychiatric+patients+in+institutions+of+care,+
falls+denote+a+patient+safety+problem+that+most+often+results+in+grave+head+injuries+and+hospital+stays.
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Cuomo, A., Koukouna, D., Macchiarini, L., & Fagiolini, A. (2021). Patient safety and risk management in mental health. Textbook of patient safety and clinical risk management, 287-298. https://library.oapen.org/bitstream/handle/20.500.12657/46117/1/2021_Book_TextbookOfPatientSafety
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Helmer-Smith, M., Mihan, A., Sethuram, C., Moroz, I., Crowe, L., MacDonald, T., … & Liddy, C. (2022). Identifying primary care models of dementia care that improve quality of life for people living with dementia and their care partners: an environmental scan. Canadian Journal on Aging/La Revue canadienne du vieillissement, 41(4), 550-564. https://www.cambridge.org/core/journals/canadian-journal-on-aging-la-revue-canadienne-du-vieillissement/article/identifying-primary-care-models-of-dementia-care-that-improve-quality-of-life-for-people-living-with-dementia-and-their-care-partners-an-environmental-scan/EBDED241B23E1CBFA98A7DA176B4E989
Potts, C., Mulvenna, M., O’Neill, S., Donohoe, G., & Barry, M. (2023, September). Digital mental health interventions for young people–review of the literature. In European Conference on Mental Health. https://pure.ulster.ac.uk/en/publications/digital-mental-health-interventions-for-young-people-review-of-th