BHA FPX 4020 Assessment 1 Healthcare Problem Analysis

Healthcare Problem Analysis

Student Name

Capella University

BHA-FPX 4020

Professor’s Name

Submission Date

Falls are one of the most frequent adverse events that occur at healthcare providers throughout the United States (US), including Ascension St. Vincent Hospital in Indianapolis, IN. Patient falls have been identified as happening up to 700,000 to 1.3 million times per year, resulting in injuries to 30% to 50% of the patients annually, according to the Agency for Healthcare Research and Quality (2025). Patient falls are a big problem in keeping patients safe. In addition, patient falls impact patient health status, cost the health care system, and reduce the quality of patient care.

Problem Identification and Rationale

One of the major risks to patient safety and effective organizational performance is patient fall risk. Falls involving patients in acute care units, and where the patient experiences any type of injury due to falling, can be regarded as a preventable matter. These patient injuries can lead to adverse effects on a patient’s health, prolong the stay time in the facility, and increase the cost of providing health services. The Ascension St. Vincent Hospital has a varied patient population comprising older patients and patients with various chronic diseases. Falls in acute care hospitals and injuries resulting from the falls may be considered an important patient safety problem.

Effect on Patient Care and Outcome

The direct and measurable impact of patient falls on patient outcomes has been documented. Research has revealed that 25-30% of falls that occur in patients result in moderate and even severe injuries, such as bone fracture, brain damage, and internal hemorrhage (World Health Organization, 2021). Moreover, these injuries result in additional complications, such as immobility, pressure ulcers, and infections. Furthermore, fall victims stay an extra 6-12 days in the hospital, which increases the chances of developing other diseases found in hospitals (Hodgson et al., 2023). The incidence of patient falls is a patient outcome that has an impact on patient satisfaction with healthcare services.

Economic Implications

The budgeting part of health care facilities is highly influenced by fall incidents. The economic loss to the healthcare system in the USA is over $50 billion per year caused by falls leading to injury (as detailed in an article). The cost associated with patient care in the USA healthcare system after a fall is $14,600 per 1000 patients at different severity levels (Dykes et al., 2023). Furthermore, falls with injuries might be regarded as a healthcare-associated event, and the healthcare facility may not be reimbursed by Medicare for the treatment of patients. Therefore, when patients fall, it has a negative impact on healthcare systems, such as Ascension St. Vincent Hospital.

Patient Satisfaction through Reputation and Quality of Care

Falls are a key part of the hospital’s safety performance results that greatly influence the image of the hospital and the satisfaction of its patients. Patient safety metrics are some of the determinants that play a role in determining the scores awarded by CMS Care Compare and other similar organizations such as Leapfrog (Centers for Medicare & Medicaid Services, 2023). Hospital averages that fall below the average for falls tend to do well on the patient satisfaction and quality assurance metrics. High patient satisfaction and retention rates are a direct reflection of the hospital’s commitment to patient safety. Patients whose institutions have a positive patient safety record are extremely satisfied and loyal to the hospital.

Problem Analysis and Measurement

he standardized quality indicators identified by AHRQ and NDNQI are used to measure patient falls. Considered most important in those situations are some measures, such as patient falls per 1,000 patient days. This measure provides a way of gauging performance in regard to such cases. The national average fall rate has been estimated at 3-5 falls per 1,000 patient days (Agency for Healthcare Research and Quality (AHRQ), 2024). The fall injury rate is also very important as it refers to the number of injuries from falls and can be measured using falls per 1,000 patient days.

Some other metrics are the repeat fall rate, which gauges the proportion of repeat falls among patients, and the risk assessment compliance rate. By consistently implementing monitoring and preventive measures, it is possible to reduce patient falls by up to 25% (Turner et al., 2022). This type of measurement instrument is available to estimate the frequency of use of standardized tools to assess risk and preventive measures like bed alarms, non-slip shoes, and hourly rounding. Through such tools, it becomes easy to estimate the risk level of patients who are likely to fall.

Industry Benchmark

Step 1: Build a Team of Professionals 

The first step is to assemble a team of professionals. The first step is to establish a team of professionals.

One of the important considerations when discussing fall prevention is to have a shared understanding of the knowledge needed and to make sure everyone involved sets up that understanding. The team involved in fall prevention would be multi-disciplined and would include nurses, physicians, physiotherapists, pharmacists, and quality improvement staff. From the literature, there is evidence that the involvement of leaders can minimise the negative outcomes (Restivo et al., 2022). All the members of this team will have different tasks to accomplish, and the reporting line will directly reach the executives. This team will meet monthly for fall trends.

Step 2: Analyzing Fall Data

Data on falls will be gathered and analyzed to determine any trends and to find high-risk areas. Data captured within the EHRs and fall reporting will offer a great deal of information about patient factors, frequency of falls and location. Incidences of falls will be calculated for every 1,000 patients per day in each department since that is the standard method of calculating it (Agency for Healthcare Research and Quality, 2025). Additional care will be needed for high-risk departments such as medical-surgical and geriatric departments. Trend analysis with dashboards will be used to analyze trends with respect to peak occurrences.

Step 3: Benchmarking

The benchmarking process entails comparing the fall rate to the national benchmark set by AHRQ and NDNQI. Those units that met a fall rate higher than the national benchmark (3-5 falls/1,000 patient days) would be required to develop plans to address the issue (Agency for Healthcare Research and Quality, 2024). A reduction in the fall rates by 15%-20% within a year is anticipated (Dykes et al., 2023). This would be done every quarter, and results presented to senior management.

Step 4: Identifying the Root Cause

Root cause analysis will be done to find out the root causes of these fall injuries that were experienced by the patients. Some causes may be side effects of medicine, hazards of the environment, lack of staff, or the inability of patients to walk unaided. The workflow analysis and staff interview will allow the identification of any weaknesses and non-compliance with the safety protocol. According to research, falls that occur in hospitals can be prevented with proper precautions by the staff (Gervasi et al., 2025). Relevant root cause analysis is a necessity to solve the root cause.

Step 5: Solution Implementation Based on Scientific Data

Evidence-based interventions will be implemented to reduce the risk of falling. These strategies will include a change to hourly rounding, bed alarms, provision of non-slip shoes, and educating patients. According to research, hourly rounding is known to result in decreased cases of falls (Davis et al., 2024). Reviews will take place to minimise the use of medicines which can lead to falls, including sedatives. Multifactorial falls prevention interventions have been shown to decrease fall rates in hospitalized patients.

Step 6: Monitoring and Follow-Up

Progress monitoring is important and needs to be done on an ongoing basis. Falls will be assessed every month, and compliance will be assessed every week. By measuring in real-time, any areas that need to be improved in terms of performance measurements will be detected. In the event of increased falls, the necessary actions will be taken immediately (Jehu & Skelton, 2024). Semi-annual performance reviews by leaders will take place.

Step 7: Education and Communications

Education is an important part of ensuring safety culture. The staff will engage in annual training on fall prevention, which includes simulation that may help them move towards safe behaviors (Gore & Schrems, 2025). The effectiveness of the units will be evaluated using performance reports. Rewards will be given for successful performance by high-performing units. Communication promotes cooperation and compliance with safety practices.

Conclusion

Patient falls at Ascension St Vincent Hospital are a problem that can be most effectively prevented in the hospital. Using indicators, comparing statistics nationally, and applying evidence-based practice in hospitals may help in reaching the goal of reducing the number of patient falls. This will not only have a positive impact on patient safety but will also benefit the company by improving its profitability. As part of the healthcare transition to value-based care, medical practitioners have been debating patient falls as a subject.