NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Student Name

Capella University

NURS-FPX 6212 Health Care Quality and Safety Management

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Quality and Safety Gap Analysis 

Healthcare organizations constantly strive to maintain patient care quality and enhance patient safety. Yet, several quality and safety issues emerge, highlighting the need for immediate practice changes. This paper delves into the quality and safety issue of in-patient falls as a topic of interest within _____________ (mention the name of your organization/practice setting). The practice gap in this clinical setting includes insufficient preventive measures and patient safety, increasing the prevalence of inpatient falls. This analysis addresses the gap in achieving desired practices by proposing changes to enhance patient quality and safety outcomes. 

Organizational Problem and Knowledge Gaps/Areas of Uncertainty

Patient falls within the healthcare settings are the most significant adverse events. These falls lead to various adverse consequences, such as injuries, fractures, internal bleeding, disease complications, and deaths. Approximately 1 million patients experience falls during their hospital stay in the United States (LeLaurin & Shorr, 2020). Almost 1/3rd of these falls are preventable (AHRQ, 2019). Various extrinsic risk factors lead to preventable falls in healthcare settings. Staffing shortages and burnout are common factors leading to quality and safety issues. According to Dall’Ora et al. (2020), understaffed units and provider burnout diminish the quality of care practices.

Consequently, this results in patient falls, medical errors, and adverse patient outcomes. Minimal assistance to patients, whether due to understaffing or inadequate resources, can exacerbate the risk of patient falls. Environmental issues within healthcare facilities, such as slippery floors, inaccessibility to facilities, low nurse-to-patient ratio, and overcrowding, also contribute to falling risk (Stathopoulos et al., 2021). 

Failure to address this issue leads to poor consequences such as increased healthcare costs, prolonged hospital stays, legal liabilities, undermined patients’ trust and satisfaction, and damage to institutional reputation. Several knowledge gaps and uncertainties persist, hindering comprehensive prevention strategies. Additional information is required related to the effectiveness of existing fall prevention interventions, the interplay between individual patient characteristics and environmental factors, and the role of emerging technologies in fall prevention. Thus, a comprehensive understanding of inpatient falls is imperative to improve patient safety in healthcare settings.

Practice Changes 

The practice gap in healthcare organizations stemming from insufficient preventive measures and ineffective patient safety management requires adequate practice changes. This gap leads to compromised quality and safety outcomes, as evidenced by the high prevalence of inpatient falls and associated injuries in the healthcare organization. The proposed practice changes are implementing comprehensive fall risk assessment protocols, staff education and training, and establishing an interdisciplinary fall prevention team. 

  • Comprehensive Fall Risk Assessment Protocols: Standardized protocols for assessing fall risk upon admission and throughout the patient’s stay can help healthcare providers identify individuals at high risk of falls, guiding preventive measures. These protocols include using fall assessment tools like the Morse Fall Scale or Hendrich II Fall Risk Model. According to the Joint Commission International Accreditation (JICA) Standards for Hospitals, healthcare facilities should reduce the risk of patient falls by employing appropriate screening and assessment. Thus, standardized fall risk assessment tools are essential to stratify fall risk and guide tailored interventions (Strini et al., 2021). This proposed change assumes that regular fall assessment based on modifications in patient condition ensures proactive management of risk factors, reducing the likelihood of falls 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

  • Staff Education and Training: Shaw et al. (2020) emphasize the importance of staff training and education in preventing fall incidences within healthcare settings. These educational interventions, integrating behavioral change models and theoretical frameworks, ensure changes in the quality of practices and reduce the likelihood of in-patient falls. It is presumed that increased awareness and knowledge of best practices can empower frontline caregivers for fall prevention. Ultimately, this will enhance patient safety and reduce adverse outcomes.

  • Multidisciplinary Fall Prevention Teams: Interprofessional team members such as clinicians, pharmacists, physical therapists, and environmental specialists can leverage collective insights to tailor fall prevention interventions to individual patient needs, address environmental hazards and monitor outcomes. These teams foster collaborative efforts with diverse expertise to provide comprehensive patient care (Gemmeke et al., 2022). Assumptions underlying this proposal include the belief that interdisciplinary collaboration facilitates holistic assessment of patient safety risk factors, implementation of multifaceted interventions, and continuous quality improvement initiatives.  

Prioritization of the Proposed Change Strategies 

While all the proposed changes are essential to reduce fall incidence rates, staff education and training emerge as the most crucial initiative, ensuring the highest priority score. According to the literature, healthcare providers’ education is recognized as a priority measure to improve patient safety in healthcare settings (Shaw et al., 2020). This training enhances staff competency and fosters a safety culture, aligning with the organization’s strategic goals of quality patient care. Staff education is prioritized as well-trained staff are better equipped to recognize fall risk factors, implement evidence-based interventions, and respond promptly to fall events.

This minimizes adverse outcomes and enhances patient safety. Secondly, implementing comprehensive fall risk assessment protocols is next on the priority list, as identifying the risk factors relies heavily on staff competency and adherence to standardized protocols. It is essential that healthcare providers accurately utilize assessment tools and interpret findings. Finally, establishing multidisciplinary fall prevention teams is prioritized. While these teams are valuable for collaboration and holistic assessment (Gemmeke et al., 2022), the success of interdisciplinary teams hinges on the proficiency of providers, which is enhanced through robust staff education initiatives. 

Quality and Safety Culture and its Evaluation 

Implementing these proposed practice changes will foster a culture of quality and safety by empowering staff with the knowledge and skills to prevent fall events by taking ownership of their actions. According to Shaw et al. (2020), empowering healthcare providers enhances the quality of healthcare delivery and allows them to employ strategies for patient safety. Similarly, the standardization of practices through comprehensive protocols will ensure a consistent and thorough evaluation of each patient’s fall risk, reducing the possibility of missed risks and promoting a data-driven approach to fall prevention (Strini et al., 2021).

This approach will foster a culture of continuous improvement and quality care. Lastly, multidisciplinary teams will create a platform for open communication and collaboration between healthcare professionals. This allows for a holistic approach to patient care, addressing fall risks from various perspectives leading to a more comprehensive safety strategy (Gemmeke et al., 2022). However, there must be criteria to evaluate this quality and safety culture. This includes monitoring fall rates over time through dashboard data. A consistent decrease in falls indicates the effectiveness of the implemented practices (Turner et al., 2022).

Moreover, it is essential to gauge staff’s perception of safety through surveys, revealing areas for improvement and identifying knowledge gaps. Finally, observing the level of open communication around safety concerns is vital. Staff should feel comfortable reporting near misses and discussing potential risks without fear of reprisal. These criteria provide valuable insights into the effectiveness of practice changes, leading to ongoing quality improvements.

Organizational Culture Affecting Quality and Safety Outcomes 

While organizational culture refers to shared values, beliefs, and behaviors, hierarchy is an organization’s power and decision-making structure. These aspects are significantly influenced by leadership and management abilities. Eventually, all these aspects impact the quality and safety within an organization. Positive organizational aspects, emphasizing open communication and prioritizing patient well-being, result in reduced fall errors, improved staff morale and engagement, and increased reporting of near misses and safety concerns (Lu et al., 2022).

Conversely, a culture prioritizes profits over safety, discourages reporting errors, has rigid hierarchies with limited shared decision-making environment, and authoritarian leaders encounter increased safety concerns, decreased staff engagement, and under-reporting of unsafe events, leading to delayed identification and resolution of safety issues. This analysis assumes that prioritizing safety through organizational culture and hierarchy improves quality outcomes. It also assumes that staff feel encouraged in a culture that promotes open communication and shared decision-making, creating a sense of ownership and continuous quality and safety improvements. 

Justification of Necessary Changes in an Organization

Implementing necessary changes to mitigate adverse quality and safety outcomes related to falls requires a multifaceted approach. Our organization requires changes in leadership practices that promote patient well-being and show a strong commitment to providing resources for fall prevention practice changes. These changes will give direction to the team and ensure the necessary support for implementing and sustaining effective initiatives (Els & Meyer, 2024). Moreover, the organization requires effective communication channels to timely and accurately disseminate information regarding fall prevention and the effectiveness of practice changes among healthcare teams.

Establishing necessary quality processes, including regular audits and performance evaluations, is imperative as they help identify areas for improvement and ensure staff adherence to evidence-based practices in fall prevention. Lastly, the organization must strengthen interprofessional collaboration through shared- decision-making, regular team meetings, and effective communication as it fosters teamwork among healthcare disciplines in addressing multifactorial aspects of fall prevention (Gemmeke et al., 2022). Yet, some knowledge gaps persist related to the optimal staffing ratios and the impact of organizational culture on staff adherence to fall prevention protocol.


AHRQ. (2019, September 7). Falls. psnet.ahrq.gov. https://psnet.ahrq.gov/primer/falls

Dall’Ora, C., Ball, J., Reinius, M., & Griffiths, P. (2020). Burnout in nursing: A theoretical review. Human Resources for Health18(1), 41. https://doi.org/10.1186/s12960-020-00469-9

Els, R. C., & Meyer, H. W. (2024). The influence of leaders’ attitudes and commitment to quality management of training on organisational excellence: A mixed-methods study. Human Resource Development International, 1–31. https://doi.org/10.1080/13678868.2024.2315925 

Gemmeke, M., Taxis, K., Bouvy, M. L., & Koster, E. S. (2022). Perspectives of primary care providers on multidisciplinary collaboration to prevent medication-related falls. Exploratory Research in Clinical and Social Pharmacy6, 100149. https://doi.org/10.1016/j.rcsop.2022.100149 

LeLaurin, J. H., & Shorr, R. I. (2020). Preventing falls in hospitalized patients: State of the science. Clinics in Geriatric Medicine35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007

Lu, L., Ko, Y.-M., Chen, H.-Y., Chueh, J.-W., Chen, P.-Y., & Cooper, C. L. (2022). Patient safety and staff well-being: Organizational culture as a resource. International Journal of Environmental Research and Public Health19(6), 3722. https://doi.org/10.3390/ijerph19063722 

NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis

Shaw, L., Kiegaldie, D., & Farlie, M. K. (2020). Education interventions for health professionals on falls prevention in health care settings: A 10-year scoping review. BMC Geriatrics20, 460. https://doi.org/10.1186/s12877-020-01819-x 

Stathopoulos, D., Ekvall Hansson, E., & Stigmar, K. (2021). Exploring the environment behind in-patient falls and their relation to hospital overcrowdedness—A register-based observational study. International Journal of Environmental Research and Public Health18(20), 10742. https://doi.org/10.3390/ijerph182010742 

Strini, V., Schiavolin, R., & Prendin, A. (2021). Fall risk assessment scales: A systematic literature review. Nursing Reports11(2), 430–443. https://doi.org/10.3390/nursrep11020041

Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2022). Fall prevention practices and implementation strategies: Examining consistency across hospital units. Journal of Patient Safety18(1), e236–e242. https://doi.org/10.1097/PTS.0000000000000758 

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