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HLST273 Nursing : Systematic Review and Meta-Analysis

A frail patient, aged 84, with a history of falls, was admitted via Accident and Emergency with respiratory problems for which he was treated with Intermittent Positive Pressure Ventilation.  He was taken directly to the Intensive Care Unit where he was ventilated overnight.  His intubation was removed the next morning and he was subsequently transferred to the ward at 19.00 hours.  The Ward was busy but after visiting their relative, the patient’s family asked for bedrails (cot-sides) to be put in place and this was carried out.  At 03.00 hours the patient was found to be lying on the floor and he suffered a fractured hip and subsequently died 2 days later. 

What risk assessment/s should have been carried out for this patient and when? Please give your reasons and support your response from the literature.
Should the bedrails have been placed on the bed by the nursing staff?  Please justify what you decide.
What other risk avoidance measures could have been taken and how does the ward culture impact care?
Following this significant adverse event, what action could the clinical leader take to improve the quality of care in the ward?

Also put include points touching your learning outcomes for this model. These are:

LO1: Propose factors that determine the provision of healthcare based upon the requirements of the individual.
LO2: Determine the role of clinical governance systems and their influence in quality improvement in the healthcare context.
LO3: Examine the evidence base that informs a selected patient safety initiative.
LO4: Critically reflect on the impact situational awareness and human factors can have on complex care delivery.
LO5: Illustrate the contribution of clinical leadership to quality care provision in adult health care.



Falls and associated injuries are common and serious issues which affect the older people. The people with the age of 65 and above are susceptible to falls and it has been found that 30 percent of people older than 65 years and also 50percent of those older than 80 years at least falls once in a year in the United Kingdom (Gazibara et al., 2014). The impact of falling include, pain, mortality, distress, loss of confidence and loss of independence. However, falling can affect the quality of life of the people affected and even those of their families. The patient should be routinely asked if they had fallen earlier, the frequency of fall, the context of the fall and the features associated with the fall. These ideas could prevent the patient from further falls in hospital.The essay will address the case of patient aged 84 who was admitted to hospital with a history of falls.

Risk assessments

The patient should have been assessed on the risk of falls by the use of comprehensive assessment approach. This is the method which nurses and geriatricians use to examine and treat a patient who is at risk or even the one who had recently fallen. However, this approach may be part of overall geriatric assessment or just particular to the risk factors for falling and one of the parts of pots fall evaluation (Aranda-Gallardo et al., 2013). Furthermore, the comprehensive assessment involves in-depth medical assessment of the previous cognition, gait, and falls, strength, balance, chronic diseases, nutrition, chronic ailments and other medications. The approach could have assisted the patient in identifying the intrinsic factors which could have been treated to minimize the possibility to fall. However, the multifactorial falls risk assessment should have been done on the patient (How croft et al., 2013).   This involves identification of falls history, evaluation of osteoporosis risks, the assessment of visual impairment and the assessment of the cognitive impairment.


align: justify;">Bedrail should have been placed in the bed to prevent the patient from falling. Bedrails are crucial for adults’ hospital patients to keep them from falling. Studies have shown that introduction of bedrails in the beds of fall patients prevent them from falling (Moore et al., 2013). Practical and ethical considerations imply that bed rails are appropriate for only patients who need them. As for the patient in the case study, there was a need for bedrail because the patient had a history of falls. Thought the patient eventually fell, there was a need for the nurses to know that fatal bedrail entrapment can be prevented by getting rid of outdated equipment. They should have ensured there is a good combination of bedrail, bed and mattress and I believed that it could have saved the patient

Fall risk avoidance measures and culture on care

Situational awareness and human factors such retrogressive cultures, individual perception on medications and fear to undertake certain interventions are great factors which affect service delivery on elderly hence education should be offered to assist patients to overcome them (Toebes et al., 2015). Education interventions are significant measures meant to increase the knowledge on the fall preventions and also offered appropriate knowledge to patients concerning their risks of falling and strategies of fall preventions (Toebes et al., 2015).  The approach is one of the programs which results in positive outcomes like behavioural change, increased mobility and decrease the fear of falling. The education measures commonly take the form of fact sheets and the evidenced-based items. It offers preventive measures which can assist them from falling. They also come up with a check list that can assist them to identify all forms of fall hazards at their homes and settle on the necessary preventive measures. Furthermore, the affected patients are informed on places where they can get help in case of falls in order to shun the long lie condition. Nurses have a great role in ensuring that patients are well educated on matters concerning their health (Olsen & Bergland, 2014). The psychology department has played role in many hospitals in the United Kingdom in counselling patients about the safety of their health. However, the clinical leadership should increase their engagement with the families of the patients and not patients only. The move will ensure that family members will be in a position to assist the patients at their homes.

Another risk measure is the home assessments. It involves clinicians visiting the homes of the affected patients and evaluate how the environment of the home is suitable in relation to patient's mobility. The conditions of the elderly should always be checked to ensure that they are safe from any risk factors and this calls for frequent checkup and assessments. An assistive equipment is then prescribed to the patients in an aim to reduce the falls within the surrounding of home (Kendrick et al., 2014). Clinicians will eventually develop adaptations through the installed assistive equipment in order to enhance the independent living and also alleviate the possibilities of falls.

Technology-based interventions have been used in many types of falls prevention instances. It encompasses diagnosing and treating the falls, detecting falls, keen adherence to the interventions and alerting the clinicians in case of any falls. Technology is also an important tool as it helps the concerned patient to assess themselves (Potter et al., 2017). The innovations have provided a great opportunity for lessening the cost and reducing the burden on the healthcare and also improving effectiveness and quality of the service offered.The old patients should be monitored closely. It is important for family members to hire someone who could be looking after the sick each and every time to avoid any instance of fall. This is the best method in cases where the patient has developed falls frequently.

The kinds of foods and drinks which the elderly eat is one of the health initiative which assist patients from contracting diseases. Eating food with lots of fats can lead to overweight thus risking the patients to fall and other conditions such as hypertension. However, the use of alcohol is not a good practice for elderly people. It results in loss of coordination and it can exaggerate and affect functions of some medicines (de Brito Vieira et al., 2016).    Also, smoking cigarettes is another lifestyle which has a great potential of affecting the mass density of the bones. However, by using excessive cigarettes and alcohol, it can contribute to osteoporosis. All these can increase the risk of falling and it is important to teach the patients about the importance of reducing or even abstaining from cigarettes and alcohol so that they can reduce the risks of falling.

Elderly people are susceptible to other conditions which can increase their risks to fall and even other illness.  For instance, they are susceptible to conditions which affect the quality of their bones. For instance arthritis and osteoporosis.  There is a need to be subjected to frequent assessment so that these conditions can be identified as early before leading to major fatalities. These people should be frequently under calcium supplement drugs which are in a position to boost the strength of their bones (de Brito Vieira et al., 2016). However, they should be given vitamin D supplements to assist in building up the weak bones.

In relation to the effects of ward culture on the care offered in the hospital, the patient in the case study was greatly affected by the inefficiency of the nurses; the staffing levels have been linked to adverse events in health care. It was evident that the nurses were busy to mean that there were not enough nurses to attend the patient and even offer close care which could have prevented the patient from falling (Giles et al., 2015).  Quality care services are crucial in any hospital but due to greed for money, there exist some hospitals which accommodate patients which exceeds the standard ration of the existing staff. The clinical leadership should work based on the set regulations and ensure that the staff personnel are enough to meet the needs of the patients. They should not just admit patients because they are in a position to attend them but they should base their decision on the ability to offer a quality care.

The use of single bed and variable acuity room have been found to be more conducive for patients care. These rooms reduce stress among patients and reduce the levels of noise which can affect the recovery process of the patients. Environmental noise and lights can cause interruptions and sleep disturbance which can make the patients fall out of their beds. Single rooms allow more privacy and comfortable environment which patients can get more support and education about their condition (Giles et al., 2015). The design of the room of patient allow much flexibility and also can be transformed to achieve changing acuity.  With these kinds of rooms, the care of the patient has been found to facilitate better medication, reduced medication errors and falls. In order to improve the services offered in the healthcare, the nursing leadership should do intensive research on how better conducive environments can improve the conditions of the patients. If they found that the existing literature is not efficient, they should conduct their trials and come up with a genuine outcome so that they will be in capable to bring changes that suit the needs of the patient.

However, the decentralized nursing workstations are one of the factors which contribute to the falls of the patients in the hospital's bed. Nurses need to be close each and every time to the patients, however, if there get their medical suppliers such as medicine and equipment from different rooms, their movements up and down could lead to fatigue and reduce the efficiency. Anything can happen to the patient each time the nurses are away. Centralized workstations assist the nurses to increase patient surveillance and close inspection of the patient. However, in regards to the staff, nurses should not work for long hours in a day (Rheaume & Fruh, 2015). In situations which nurses work for more than eight hours, there are high possibilities that they will not be in a position to work efficiently to meet the need of the patients. Long hours of work can result in fatigue and a nurse can end up making mistakes that can risk the life of the patient. It is therefore, necessary for the governance of nurses to ensure that their staff work within the standard time to ensure they maintain their efficiency at work

The nursing leadership should work hard and change the design of the wards and the work how nurses work within the ward. It is crucial to work at one point so that the care of the patients can be effectively worked out. The patients will be in a position to call for help at any time when they feel their positions should be changed or any other kind of help (Giles et al., 2015). The clinical leadership should also realize that the needs of the elderly are different from those of other patients hence close relationship should be maintained between nurses and the concerned patients.

Hospitals that are large enough to accommodate the family members to the care units assist effective care of the patients. Family members have been found to understand well the needs of the patients. Some patients cannot conceal their issues in front of the nurses but they can tell their families instead. By accommodating, family members to the care units can be a solution to decentralized care units where the movements of the nurses can result to falls of the patients (Rheaume & Fruh, 2015). Different hospitals have different policies regarding the inclusion of patients in the care of the patients. There are those who believe that nurses should be given all responsibility and family members should only visit occasionally. However, others have worked out and included a few number of family members to care their patients. It is the responsibility of any health care to ensure and acknowledge that the needs for the elderly and any other patient should be paramount. They should be offered a care which their members of the family participate fully in order to offer other services which the nurse might not be in position to offer due to some cultural difference

The kinds of beds which the hospitals use for people with risks of falls also is another factor which can influence the type of care of the patient. A raised bed can risk the patient to fall. The quality of the mattress used also should not be high density that can allow free movements of the patient with the bed (Giles et al., 2015). However, it should be compatible with the bed in such a manner that it cannot get tilted and risk the patient to fall. These beds also should have bedrails each and every time based on the assessment done on the patient before being admitted

Individual factors have a great impact on the care offered to the patients. Based on the age and the stability of the elderly, the floor of the hospital dictates the care which should be provided to them. The wards which have slippery floors risk the patient to fall. It is advisable for all wards to have rough flows which can make the patient move freely and smoothly without any risks of fall.  The hospital floss and corridors also ought to be free of any obstacles which can stumble the patient when moving in and out.  Majority of the elderly people admitted in hospitals have eyesight and other sensory-related problems. As a way to ensure that their needs are catered, the wards should have convenient lighting within the room (Rheaume & Fruh, 2015).   There are patients who need more lights while others need little lighting in the room. In order to achieve their needs, these patients should be placed on different rooms with respective lighting conditions.

Clinical governance have a big role in ensuring that nurses offer quality health. They do so by evaluating the work of nurses. Different nurses have a different way of doing things. There are those who love their work while others are lazy but any form of laziness in unethical practice. Such nurses can keep procrastinating the issues of the patients and end up failing to deliver what the patients’ needs. With such culture in the ward, patients are at risk of encountering fatalities due to negligence. Clinical governance should conduct the assessment of their staff through patients (de Brito Vieira et al., 2016). The responses collected will be used to caution the lazy and unethical staff who risk the life of the patients.  The move will ensure that the nurses work under the set regulations.


Falls among the elderly patients have been common among a significant percentage of people in the United Kingdom.  Falls have lots of consequences to the concerned patients as well as their families. In regards to the context provided, the was need for some assessments to be conducted before admissions of the patients so that it could have been easy for the nurses to save the patient from further falls. However, there was necessity of bedrails for the patient. It was meant to ensure that it prevents the patient from falling. Though it did not work, there is a possibility that nurses were not close to the patient at night. There are many factors which have been associated with the falls among the elderly people and it calls needs for nurses to come up with better strategies within and outside the healthcare facilities. In addition, wards culture have a significant impact on the healthcare services provided. If not for negligence and lack of adequate staff in the hospital, I believe that the very patient could not have ended up dying. It is crucial for leadership of the nurses and health care governance to ensure that the safety of the patients are prioritized during and after admission to the hospital.


Aranda-Gallardo, M., Morales-Asencio, J. M., Canca-Sanchez, J. C., Barrero-Sojo, S., Perez-Jimenez, C., Morales-Fernandez, A., & Mora-Banderas, A. M. (2013). Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC health services research, 13(1), 122.

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