Among the vital healthcare, workplace values stand out, guaranteeing the security of patients and preventing falls with all the potential accidents that might happen as a result – fractures, deep cuts and internal bleeding. Annually, 700,000-1,000,000 Americans fall in hospital wards, a source of the rise in healthcare service utilization (AHRQ, nd ). Notably, studies conclusively ensure that almost one-third of these falls can be prevented through advanced measures of managing a patient’s underlying risk factors and redesigning the hospital environment. The team debrief, commonly known as post-fall huddles, is critical to the fall-risk reduction programs’ practice. These team huddles following a patient’s fall will be when the group members come together to discuss the events after happening, figure out the contributing factors, and find preventive strategies that will be a proactive approach rather than a passive case review. In this paper, an attempt is made to learn from the literature how post-fall huddles are practised and if the current practice in our facility can be modified better to serve our patient’s information needs during critical incidences. A multifaceted approach to fall prevention is necessary beyond merely addressing the patient’s underlying fall risk factors to enhance the hospital environment’s effectiveness in safeguarding the patients’ well-being.
Evidence-Based Practice of Post-Fall Huddles
The research on the post-fall huddle coincides with many healthcare facilities that show the supportive role of this discussion in improving fall-risk reduction projects. These meetings with the team members occur right after the patient’s fall. The objective is to analyse the incident thoroughly, find the contributory factors, and develop feasible action plans to prevent fall recurrence (AHRQ, nd ). This approach is about more than just the safety issue; for example, it is about the fall itself. Still, it is also about a safety and continuous improvement culture within healthcare organizations.
The Agency for Healthcare Research and Quality(AHRQ) has focused on forming a fall prevention program. Thus, the AHRQ has recommended developing, implementing, and sustaining an all-around approach that includes identifying and managing a patient’s underlying fall risk factors and ensuring the hospital’s physical design and environment are fit for patients (AHRQ,n.d). Even more, to substantiate the success of the huddle post-falls, Jones et al. (2019) found that it correlates with the prevention of re-falls and changing the views of safety from different staff members’ perspectives. The information provided by the research shows that involving post-fall huddles may lead to more positive evaluations of the safety culture domains of hospital departments, including organizational learning, non-punitive error responses and teamwork (Jones et al., 2019).
Buckner and Sherry (2019) introduce the practical use of huddle–fall in nursing homes and make quality improvement successful by making huddles focused on assessing the root cause of the fall. The approach covers evidence-based models to prevent ripped-off falls and identify causes of falls in the facility on a room-by-room basis, helping to align with the overall goals of improving safety and efficiency in healthcare (Buckner & Sherry, 2019).
Heng et al. (2020) discuss hospital fall prevention through patient education and a scoping review not directly targeting huddles after a fall, which, however, points out the multifaceted nature of the various fall prevention approaches. The hospital-based research done by these healthcare professionals shows that the specialized patient education programs correctly designed can have a profound effect on knowledge, self-perception as a fall risk, and empowerment, which, in turn, can lead to reduced falls within a hospital.
Post-fall huddles can be used as an evidence-based strategy to minimize the incidences of repeat falls that can compromise patient safety. These conferences occupy an essential place in a complex system of measures of a general fall prevention policy, which includes patient education, staff training and the environment arrangement. The results of retrospective post-fall team huddles in their ability to lessen recurrent falls and provide a safety culture across many healthcare facilities indicate the significance of these meetings for ongoing attempts to improve patient outcomes and prevent non-essential healthcare utilization related to falls.
Organization’s Current Practice of Post-Fall Huddles
In our organization, the post-fall e-huddles are conducted by a selected team of staff, usually represented by the house supervisor and nurse in charge, and primarily assigned participants to the fallen patient. Although they are signed to audit and analyze the cause of the fall episode, this method embraces only one of the best guidelines of having a comprehensive interdisciplinary team that involves the direct being facility (LeLaurin & Shorr, 2019). A confined range may be blocking people from correctly understanding the diversity of factors that lead to falls, so great measures should be taken to prevent them.
One of the practical barriers to employment of good practice is the challenge of involving all the staff in such hurdles. Numerous personnel are convinced that lack of time or any other duties have to do with the fact that they do not participate, implying that the allocation system does not allow staff members to be part of the process of knowledge and improvement. It embodies an imperative to build organizational routines and processes that uplift participation in post-show spot huddles, thus enabling a more robust, diverse, and solid range of viewpoints on patient falls to be considered.
Nevertheless, those challenges regarding the fall huddles as a resource for promoting patient safety are always realized inside the organization. The current process disempowers the practice by providing education education and preventive resources. However, the new model is not fully adopted because the staff is not engaged and the resources allocated are insufficient, so the existing process cannot have perfect outcomes. Further, efforts will be focused on providing future fall huddles with greater scope and effectiveness by building a more robust network with more interdisciplinary teams and tackling any downfalls that hinder proper staff input. This initiative showcases the organization’s concern for continued quality improvement and creating a more safety-conscious culture within patient care.
Gap Analysis
The team huddles conducted in our organization after the fall reflects a gap in the organization’s procedures compared to those cited in the best practices. Firstly, the gap takes the form of varying levels of interdisciplinary participation and overall depth of the fall incident forecasting. Although our huddles have now engaged with a subset of participants, mainly the house supervisor, charge nurse, and a regular nurse, a superior recommendation exists that takes heir to an inclusive approach (Heng et al., 2020). An ideal approach is to include almost every participant in the healthcare profession, therapists, pharmacists, and direct care staff, to have no stone left unturned.
Another critical gap is the broader depth of the outcome of the post-fall analysis. Regarding huddles, our organization’s priority is to focus on the issue of falls. However, it is usually not extended to other issues such as system designs or options applicable in future cases that may prevent this. This is primarily different from the recommendations of the best approach, which entails a profound and all-inclusive investigation of causative factors and executing prevention plans that will utilize several diverse approaches.
Closing these gaps involves the organizational commitment to sharpening involvement in post-fall huddles, building their analysis and learning from each event. Although switching to a system emphasizing interdisciplinary teams and an encompassing approach to fall prevention may be complex and different from the current practice and standards, this is the only adequate option to achieve patient safety to the highest possible level.
Barriers to Best Practice Implementation
Implementing the post-fall huddles practices in our organization faces significant barriers. Lack of adequate staff participation is another hardship; usually, fellows number up to several, so the team gets smaller, and as a result, the whole investigation process turns out superficial and not interdisciplinary. This drawback is partly due to a high load of work and the need for more staff. Therefore, it takes much work for the new staff to present their point and comprehend the whole scrum process. One of the obstacles is the need for an articulated model for the huddhurdlest, who are responsible for getting the data, analyzing it in different ways and acting upon it. A unified transition would allow for all factors to be considered and systematic changes to be made. With that, it is easy. Additionally, there is individuality between personnel; hence, some might not acknowledge staff debriefing as an integral part of patient safety. Such a phenomenon may, for instance, result in a low interest rate and, as a result, in a decrease in initiatives aimed at fall cause root finding and the development of appropriate solutions.
Overcoming these barriers requires strategic solutions to be implemented, such as the reorganization of staffing for the wide range of participation, the development of the standardized huddle protocol, and the initiatives to build a culture of deep regard for patient safety and the recognition of the significance of post-fall huddles in the improvement of care outcomes.
Strategies for Bridging the Gap
To bridge the gaps and create a pathway for successful post-fall huddle implementation, leadership forces a multi-strategy strategy focused on communication principles, leadership empowerment, and a strong safety culture. Essential tactics aim to provide obligatory and introductory staff training, which should accentuate the unity importance of post-fall huddles in patient safety together with the equipment team with skills needed for effective post-fall huddle participation (Jones et al., 2019). Such training courses should involve a standardized huddle strategy emphasizing multidisciplinary staff teamwork.
Besides that, policy changes should be conducted for post-fall huddles to be integrated into the new normal of patient care, the way things were done before, with specific roles for each staff member. Intensifying communication avenues within the organization can be an excellent approach to creating information corridors for enhanced and more extensive talks. These means of communication create an environment where safety and related concerns are discussed without fear because every worker is free (Zajac et al., 2021).
Leadership is the critical agent in this process, providing assets to set the environment for safety and create an example of the values of a safety-first culture. Leaders can create an internal sense of personal possession and commitment around the team by actively holding huddles and acknowledging staff members for safety empowerment improvements. Hence, staff retains the momentum to step up and participate in the safety culture.
In conclusion, the gap analysis has shown essential juices between the current actions and corrections activities. It has revealed the necessity of adopting more amenable and valuable strategies. This paper is geared towards establishing strategies that lead to universal participation by the care teams and applying uniform protocols for assessing falls as opposed to the current crisis management approach, which relies on subjective reporting. This is because subjective reporting is likely to be biased, thus limiting the accuracy and effectiveness of the investigations. By contrast, analyzing the falls objectively using evidence-based methods like post-fall and Stopping this breach from occurring will make the organization better; they will achieve better results for patient care, the environment will be safe, and there will be no more episodes of patient falling, which is a gain for patients, staff, and the organization itself.
References
AHRQ (n.d). Preventing Falls in Hospitals Retrieved from Preventing Falls in Hospitals | Agency for Healthcare Research and Quality (ahrq.gov)
Buckner, T. and Sherry, D. (2019) ‘Improving falls in nursing homes: A post-fall Huddle Quality Improvement Project’, International Journal of Advanced Nursing Studies, 8(2), p. 33. doi:10.14419/ijans.v8i2.27533. (PDF) Improving falls in nursing homes: a post-fall huddle quality improvement project (researchgate.net)
Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A. M., & Morris, M. E. (2020). Hospital falls prevention with patient education: a scoping review. BMC geriatrics, 20, 1-12. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01515-w
Jones, K. J., Crowe, J., Allen, J. A., Skinner, A. M., High, R., Kennel, V., & Reiter-Palmon, R. (2019). The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project. BMC health services research, 19, 1-14. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4453-y
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: state of the science. Clinics in geriatric medicine, 35(2), 273-283.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6446937/
Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance. Frontiers in Communication, 6, 606445.https://www.frontiersin.org/articles/10.3389/fcomm.2021.606445/full