0.5 / 0.5 pts
Maria learned that sometimes the alarm on patient beds (“bed exit alarm”) was not set properly. Without activation, the staff will not be alerted when the patient may be getting out of the bed, and may fall without assistance. The condition in which the bed exit alarm is not activated when it should be is
- A visual design concept
- A failure mode
- A patient harm
- A just culture
0.5 / 0.5 pts
Maria located a 16 page “quick reference guide” on how to use the bed safety features, and found out that no one on her unit actually read the guide. She should expect that
- A simplified tip sheet on bed exit alarms is needed.
- Support from senior leadership is needed to institute a “three-strikes-you-are-out” policy on the bed exit alarm use.
- Most nurses will read the 16 page guide once they have access to the guide.
- No amount of education will help until the vendor comes up with a self-activation feature.
0.5 / 0.5 pts
Maria watched a couple of nurses who had trouble in setting up the bed exit alarm and talked with them. Which of the following is the LEAST that she should expect to find out?
- Whether the on-boarding process is adequate to orient about the bed exit alarm
- Whether the hiring process is adequate to screen out unqualified nurses
- Whether the expectation to use the bed exit alarm is clear to everyone
- Whether the visual design of the bed control panel layout is confusing to some
0.5 / 0.5 pts
Maria decided to enlist the help from others to improve the alarm exit alarm usage. A unit clerk suggested that the unit clerk could tell nurses whenever bed exit alarm is not activated. To support the clerk, Maria should expect that
- A dilution of patient safety responsibility would occur between the clerk and the nurse
- Ways to remind the clerk, such as a checklist, be developed, so he or she can remember to scan the bed alarm status at the nursing station
- Nurses will reject the idea as they feel that prevention of patient falls is the sole responsibility of the nurses
- The unit clerk will ask for a pay raise because of the new responsibility
0.5 / 0.5 pts
While working on education efforts on how to use the bed exit alarms, Maria read a study by Shorr et al (2012), which concluded that multi-prone interventions increased bed alarm use in an urban hospital but increased alarm use had no statistically or clinically significant effect on fall-related events or physical restraint use. She should conclude that
[NOTE: Shorr et al (2012) is NOT a required reading. It is provided here for your reference only: Shorr, R.I., Chandler, A.M., Mion, L.C., Waters, T.M., Liu M., Daniels, M.J., Kessler, L.A., Miller, S.T. (2012). Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial. Annals of Internal Medicine, 157(10):692-699 (Links to an external site.).]
- The education efforts should be stopped since no amount of education will help fall prevention anyway
- Multiple interventions are needed to prevent falls in addition to education to increase the bed exit alarm use
- Bed exit alarms should not be used, so that nurses have one less thing to worry about
- The bed should come with a forcing function feature to prevent patients from falling
0.5 / 0.5 pts
Maria wanted to look at patient fall risks in addition to post-fall “huddles” which review patient falls that have occurred. To study the patient fall risk proactively, which of the following Maria should AVOID doing?
- She will need to gather ideas from staff on who could go wrong at each step.
- She will need to identify individual nurses who are involved in the past patient falls
- She will need to assess the impact of failures at each step on patient falls.
- She will need a team to map out the steps of the process involved in fall prevention.
