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SNPG927 Patient Safety Indicators and PDSA Cycle: Promoting Clinical Excellence Assessment 3 Answer

SNPG927: Promoting clinical excellence

Assessment 3Written Assessment
Type of CollaborationIndividual Assessment
Length2000 words

This assignment has 4 parts
  1. Identify one (1) individual indicator of patient quality or patient safetyDefine your indicator and discuss how the indicator is used to evaluate care in one specific type of healthcare setting (e.g. ICU, surgical ward, mental health unit or residential aged care facility). Your response should include details about the indicatorhow it is measured and how it is used in your chosen setting. Note: Your indicator must focus on a process or outcome measure that is experienced by patients in a healthcare setting and it must be measurable (250 words)
  2. Provide a summary of the literature on your chosen indicator. This literature review should explore your indicator and how it is used to improve care. Note: The literature review is not focused on the problem e.g. pressure injuries OR falls, but rather on how the indicator is used in different settings to measure the safety and/or quality of care and improve care over time (1000 words)
  3. The next step is to use this indicator to solve a clinical problem using 3 small- scale PDSA quality cycles. Note: The use of PDSA cycles here is to demonstrate your knowledge and understanding of how PDSA cycles work. Use small-scale PDSA cycles to test components of care related to your indicator. (500 words)
  4. Outline how you would evaluate a quality improvement program focused on your indicator. (250 words)
  5. Word counts provided above are intended as a guide
Style and formatWritten assessment


Patient safety indicators and PDSA cycle

Indicators of patient quality  

As per World Health Organisation (WHO), patient safety is the absence of avoidable harms during the process of healthcare and reduction of risk of superfluous harm associated with healthcare practice (WHO, 2020). Patient safety indicators or PSIs are considered as screening of adverse events that the patients might experience during exposure to the health care system. The health care organisation can reduce the falls by improving their quality indicators. Therefore, changing the technical aspects likes electronic record system, improving staffs awareness, implementing the evidence based practice, implement the performance measurements, and accentuate the collaboration and co-ordination within the departments can improve the quality indicators(AHRQ, 2006)Studies revealed that falls occurs at the rate of 3to 5 per 1000 patients in hospitals of USA(, 2019). Furthermore, the agency of healthcare research and quality recognised that more than 700,000 patients fall each year in1 million patients in USA(, 2019In Australia, the fall rate was 3.2 per 1000 patients in 2015-16. The patients’ falls rate was increased in 2015-16 compared to 2009-10(0.8 per 1000) (AIHW, 2018). The incident is signified the importance of focusing on safety and quality of hospital facilities to reduce the rate of fall in Australia. In 2016-17, high rate of patients’ falls reported from public hospital than private hospitals (AIHW, 2018). The rate for public hospitals was 4.6 per 1000 patients whereas in private hospitals it was 1.3 (AIHW, 2018). 

In this assignment, we will discuss about the quality indicators like patients’ falls in hospitals and find out the solution through the PDSA cycle for improving the clinical practice and providing better care and services to the clients. 

Literature review 

Patients’ falls is now a major health problem in world. Patients’ falls is considered as an indicator of patient safety.  It has observed that approximately 30% of the falls caused severe injuries in hospitalised patients and increased their hospital stay(Shashank, 2017). In USA, the ageing population is expected to increase by approximately 50% within the 15 years(Shashank, 2017). If the trend of patients’ falls remains same then it can be assumed that around 49 million falls will be happed by the end of 2030 in USA (Shashank, 2017). Therefore, fall prevention program requires intensive research and quality improvements efforts that helps in planning of effective fall prevention programs (Morris & O’Riordan, 2017)In studies, patients’ falls can be considered as medical malpractice and caused due to poly pharmacy, misdiagnosis, or failure to access the high risk patients for falling (Chowdri, 2019). The use of multiple medications can have side effects that made the patients unsteady and precipitate falls. On other hand, the doctors are unable to recognise that the patient has serious illness (like stoke or brain haemorrhage) which needs proper attention and placed them in normal bed without any adequate support. According to Tsai, an older patient with co-morbidity increases their risk of falls (Chu, 2017). Thus, they require close attention and assistance due to changing physical and psychological pattern which elevated their risk of falls. 

Patients’ falls and injuries in hospitals are considered as good quality indicators of safety in patient. Reducing the incident of patients’ falls can improve the quality of care and services (Ott, 2018). The number of falls in hospitals can be reduced by implementing the fall prevention programs which includes the regular assessment of risk of falls, segregate the patients at high risk of falls, create positive relationships, and educate the patients about falls, and educate the staffs about the proper intervention of fall prevention program. As per the several studies, the front line staffs are requires effective leadership skills to prevent the medical error like patients’ falls (Ray et al., 2019). The proper training and educational advancement can promote the positive attitudes with respect towards the fall prevention intervention. The all medical professionals can work together in reducing the harmful events in hospitalised patients (Ray et al., 2019). In my care practice, fall prevention programs can be implemented with identification of cause and followed by prevention and management process. In some cases, administration of psychotropic drugs can cause patient falls and thus it need to replace to eliminate the risk. In addition, doctors can help in patient safety by investigating the root cause of falls and analyse them for improvement. The Care Quality Commission suggested that, the managing and learning from all kind of incidents (errors) can improve the skills and knowledge which can be utilised for prevention measures (Morris & O’Riordan, 2017). The continuous learning and improvement is required for elimination of barriers in communications which plays an important role in fall prevention.    

Increasing the patients’ falls indicator is not only rising the stress and burden of the sufferers but also escalating the healthcare cost and triggering the lawsuits against the organisations (Chu, 2017). It demands million of dollars for settlements due to patient injury and health consequences. In 2008, the CMS declared that no reimburse for any hospital acquires health consequences for the patients that required extended hospitals stay. It signifies that the hospital now bear the extra medical expenses of the patients suffering from falls. The nursing staffs are responsible of preventing the patients’ falls indicators in hospitals settings. They are the direct service providers to the patients and can assist the patients in their life during hospitalisations. However, they are facing difficulties in handling the patients and preventing the falls due to their workload and lack of awareness. The organisations are pressurising the nursing staffs to meet the hospitals goal to achieve the zero falls without proper intervention which reduce their work efficacy (King et al., 2016). In addition, they are blamed and humiliated by the authority and patients families when falls occurred. Studies revealed that intense pressure on nurses can cause negative consequences on patients and services. Nurses can restrict the mobility of their patients due to the immense pressure of reducing falls that can interfere with optimal recovery progress of the patients. Centers for medicare and medicaid services (CMS), identified falls as never event. The hospitals are targeting for zero falls goals which creating immense pressure on their medical staffs. It can cause unintended harm to the care givers and users (King et al., 2016). The nurses require proper support and intervention programs to provide care to the fall risk patients. Therefore, patient centered intervention can be beneficial for the caregivers and users. A study conducted by Abreu recognised that the patients’ falls rate was highest in morning an lowest in evening shifts (Chu, 2017). It can be assumed that in evening shifts the visitors are allowed to meet their patients and they can help them in their moving which reducing the falling rate. However, in morning shifts, patients are busy with their self care activities and not willing to seeking help from the nurses. In my care practice, a woman aged 65 years from arthritis under my supervision was willing to do her daily activity alone without any help of support. It was increasing her risk of falls and I was worried.  I talk to my higher authority about the matter and they asked me to educate the patient and their family about the consequences. Gradually, I initiated the positive communication with her and informing her about the patients’ falls and the associate risks. I also informed her family about her risk taking behaviour and they also make her understand about the situation. Now she is ready to take help from the morning staffs which has positive results on her health and well-being. Study reveals that fall prevention education for patients and their family can have positive impact on the overall situations (Ott, 2018). It can improve the fall prevention awareness, intervention, and self efficacy among the participants. The study conducted by Kempton, van Beurden, Sladden, Garner, and Beard (2000) suggested that fall prevention education creating awareness and reduce falls in participants (Ott, 2018). In addition, the fall prevention education can offer information about the falls and available facilities, supports, prevention process, and improve the safety indicators. Therefore, it is considered as economical beneficial tool for eliminating the risk of falls. As per the opinion of Verghese (2016), fall risk awareness is associated with fall prevention strategies (Ott, 2018).

PDSA cycle   

PDSA is known as plan do study act cycle which helps in measuring the quality of care in healthcare facilities. It can explore the evidence based practice in healthcare settings to improve the quality of care. It is based on trial and error process which implementing effective changes in care practice (Simpson et al., 2013). Patients’ falls are multi-factorial events and required inter-personal collaboration and system change approach to eliminate the risk. Individual care providers cannot able to bring significant changes on falls reduction without collaboration. Therefore, quality improvement team is required for PDSA cycle implementation. It requires effective teams which must include healthcare staffs, managers, and providers to identify the exact issue and area of improvement.   In PDSA cycle the first step is development of plan. In this respect, educating the staffs and their availability can improve the whole scenario. In many hospitals, fall prevention awareness program can able to reduce the rate of patients’ falls. The program can be implemented through seminar, poster presentation, and lecture. At the same times, it is important to educate the patients and their family about the risky behaviour of falls through hospital newsletters or internal TV channel in patient rooms. In addition, PDSA team can plan hourly rounding of the nurses for their patients can make the patients feel safe and less anxious. The process of hourly rounding can prevent the patients’ falls risk and injuries. As per Saleh, hourly asking of help can offer an opportunity to the patients to express their difficulties without any hesitation which reduce the risk of falls and increase the patient satisfaction (Simpson et al., 2013).  

The second step is do which signifies the implementation of quality services to reduce the patients’ falls. In this respect, engagement of quality and patient safety department is required for accessing the hospitals patients falls report system and adverse events report system (Smith, 2014). The implementation of quality services requires positive communication and connectivity among the team members to influence the facilities and intervention approaches. The next step of PDSA cycle is study which indicates the appropriate evaluation of implemented quality of services. The evaluation process can be achieved by qualitative and quantitative data collection process (Vonnes & Wolf, 2017). Any dissatisfactory results indicate the ineffective intervention process or incorrect application of intervention elements or inappropriate uptake of intervention in healthcare practice. The staffs and the member of the PDSA team can share their personal experiences during the periodic meetings. The overall process helps to access the positive and negative aspect of the implemented quality of services program. The last step is act which signifies the modification of existing plans for next cycle. In this stage the team members of PDSA team can modify the steps for the new PDSA cycles. In details, if the existing planning and implementation process can able to educate the healthcare providers and care users about the risk of patient’s falls but unable to reduce the rate of patients’ falls for elderly people in hospitals (Vonnes & Wolf, 2017). Thus, the team members can further modify the steps of PDSA cycle to reduce the rate of falls in elderly people in hospitals and assure the safety for them. 

Evaluate the process

At last it can be concluded that patients’ falls has negative impact on patient’s safety and increase mortality and morbidity in hospitalised patients. It is difficult to eliminate the risk of patients’ falls completely but it can be reduced or controlled by implementing the evidence based practice. It has been observed that lack of staffing, huge work pressure, lack of coordination and communications are increasing the rate of patients’ falls in hospital settings. It can be reduced by understanding the caregiver’s problems and providing the proper solutions which improve the quality of services. In this respect PDSA cycle can be applied to develop harmony between the care givers and users (Bouldin et al., 2012)In case of advance falls, the healthcare professionals should perform immediate diagnostic work up for identifying the harm of falls and report the authority to record the events of falls. The PDSA cycle requires to incorporating the internal and external customers. They can provide feedbacks about the implemented plans. In general the positive impact can enhance the acceptability of the process and improve the health indicators. The organisation should monitor the quality indicators and parameters (Burton et al., 2018). It can help the organisation to improve their quality of services through the process of standardisation. It can reduce the falls risk in hospitalised patients and improve their care and services.       

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