The document outlines a root-cause analysis and safety improvement plan to address avoidable patient falls in medical facilities. It identifies key patient-related risk factors like age, gender, mobility issues, and incontinence as the root causes. The plan calls for administering a standardized fall risk assessment tool, implementing universal fall precautions, and documenting prevention strategies. Existing organizational resources that can support the plan include facility administrators, unit staff, unit champions, and an implementation team.

1. Root-Cause Analysis and Safety Improvement Plan.
Root-Cause Analysis and Safety Improvement Plan. For this assessment, you will develop an
8-14 slide PowerPoint presentation with thorough speaker's notes designed for a
hypothetical in-service session related to the improvement plan you developed in
Assessment 2. As a practicing professional, you are likely to present educational in-services
or training to staff pertaining to quality improvement (QI) measures of safety improvement
interventions. Such in-services and training sessions should be presented in a creative and
innovative manner to hold the audience’s attention and promote knowledge acquisition and
skill application that changes practice for the better.Root-Cause Analysis and Safety
Improvement Plan.ORDER A PLAGIARISM-FREE PAPER HEREThe teaching sessions may
include a presentation, audience participation via simulation or other interactive strategy,
audiovisual media, and participant learning evaluation. 1.Build on the work that you have
done in your first two assessments and create an agenda and PowerPoint of an educational
in-service session that would help a specific staff audience learn, provide feedback, and
understand their roles and practice new skills related to your safety improvement plan (see
attached on falls) The final deliverable for this assessment will be a PowerPoint
presentation with detailed presenter's notes representing the material you would deliver
at an in-service session to raise awareness of your chosen safety improvement initiative and
to explain the need for it. Additionally, you must educate the audience as to their role and
importance to the success of the initiative.Root-Cause Analysis and Safety Improvement
Plan. This includes providing examples and practice opportunities to test out new ideas or
practices related to the safety improvement initiative. Be sure that your presentation
addresses the following, which corresponds to the grading criteria in the scoring guide.
Please study the scoring guide carefully so you understand what is needed for a
distinguished score. •List the purpose and goals of an in-service session for nurses. •Explain
the need for and process to improve safety outcomes related to a specific organizational
issue. •Explain to the audience their role and importance of making the improvement plan
successful. •Create resources or activities to encourage skill development and process
understanding related to a safety improvement initiative. •Communicate with nurses in a
respectful and informative way that clearly presents expectations and solicits feedback on
communication strategies for future improvement. There are various ways to structure an
in-service session; below is just one example: •Part 1: Agenda and Outcomes. ◦Explain to
your audience what they are going to learn or do, and what they are expected to take away.
•Part 2: Safety Improvement Plan. ◦Give an overview of the current problem, the proposed

2. plan, and what the improvement plan is trying to address. ◦Explain why it is important for
the organization to address the current situation. •Part 3: Audience’s Role and Importance.
◦Discuss how the staff audience will be expected to help implement and drive the
improvement plan. ◦Explain why they are critical to the success of the improvement plan.
◦Describe how their work could benefit from embracing their role in the plan. •Part 4: New
Process and Skills Practice. ◦Explain new processes or skills. ◦Develop an activity that
allows the staff audience to practice and ask questions about these. ◦In the notes section of
your PowerPoint, brainstorm potential responses to likely questions or concerns.Root-
Cause Analysis and Safety Improvement Plan. •Part 5: Soliciting Feedback. ◦Describe how
you would solicit feedback from the audience on the improvement plan and the in-service.
◦Explain how you might integrate this feedback for future improvements. Additional
Requirements •Presentation length: Remember to use short, concise bullet points on the
slides and expand on your points in the presenter's notes. If you use 2 or 3 slides to
address each of the parts in the above example, your presentation would be 10–15 slides.
•Speaker notes: Speaker notes should reflect what you would actually say if you were
delivering the presentation to an audience. Another presenter would be able to use the
presentation by following the speaker notes. •APA format: Use APA formatting for in-text
citations. Include an APA-formatted reference slide at the end of your presentation.Root-
Cause Analysis and Safety Improvement Plan.Root-Cause Analysis The issue of concern is
avoidable fall incidences among patients in medical facilities. Avoidable falls are common in
medical facilities, generally occurring at an approximate rate of 4.5 falls per 1,000 patient
days. About 30% of these falls result in injury while 5% result in serious injury that could be
fatal to include excessive bleeding, subdural hematomas, and fractures. In addition to
threatening the health of patients, avoidable falls also increase the cost of health care.
Patients who experience falls pay as much as $4,000 higher than their counterparts who do
not fall, and also spend more time in the medical facilities as they recuperate. Besides that,
patients who experience falls are likely to report mental harms such as loss of self-
confidence, fear of falling, and anxiety (Graban, 2018).Root-Cause Analysis and Safety
Improvement Plan. Owing to the risk of emotional harm, increased costs and significant
injury associated with avoidable fall incidences in medical facilities, there is a need to
implement strategies for preventing falls in medical settings as an important public health
and patient safety concern. This can be best achieved by conducting a root-cause analysis to
determine the cause of avoidable fall incidences before identifying strategies to address the
causes (Hickey & Kritek, 2012).Along this line, the present paper conducts a root-cause
analysis of avoidable fall incidences and presents a safety improvement plan intended to
efficiently and effectively address the problem of avoidable fall incidences in medical
settings.Analysis of the Root CauseAvoidable fall incidences within the medical facilities
settings continued to be a serious concern with the most adverse events leading to
increased health care costs, longer lengths of stay and injury among hospitalized patients.
The falls rates considerably vary by medical facility and unit type. However, there is a
general consensus that they are a common problem. The first step in preventing falls is
identifying the root cause of these events. In this regard, there is a notable correlation
between some risk factors and fall incidence. These risk factors identify the patients who

3. are more susceptible to falling and to who targeted intervention is anticipated to prevent
falls (Williams, Malani & Wesorick, 2013).Root-Cause Analysis and Safety Improvement
Plan.Although there is no definite explication of the risk factors, as there is no definitive
consensus on the number and types of risk factors that lead to falls, it is imperative that
these risk factors. That is because these risk factors have been previously targeted in other
facilities but fall incidences have not been completely eliminated. The risk factors are of two
main categories. The first category is intrinsic factors that include use of medication and
chemical agents, imbalance, musculoskeletal disorders, gender and age. The second
category is extrinsic factors that entail weaknessesinherent in the medical facility and
system in terms of teamwork, training, communication, human resources, and medical
equipment design and maintenance.The interactions between the extrinsic and intrinsic
risk factors creates opportunities for falls incidences (Perry, Potter & Ostendorf, 2016).The
present analysis focuses on patient-related factors. It is determined that although patient
falls have a multiple etiology, patient-related factors have been largely ignored. The
identified factors include gender and age. Incidences of falls and fall related injuries are
more common among females and older patients, likely the result of gender-based and age-
based physical declines. Besides that, conditions such as visual impairment, urinary
incontinence, heart disease, diabetes and arthritis are associated with age and they act as
predictors for increased risk of falls among patients. To be more precise, aging in
combination with gender and other factors such as confusion and poor mobility typically
result in falls and subsequent injuries among patients. Another patient related factor is
walking aids and balance difficulties. Additionally, poor vision is an issue of concern since it
is associated with sensory loss, false perception of the environment, poor balance and
reduced visual acuity. Also, frequent urination and incontinence is a concern with patients
having to visit the toilets frequently on frequently cleaned floors that could be slippery
(Vincent & Amalberti, 2016).Root-Cause Analysis and Safety Improvement
Plan.Improvement Plan with Evidence-Based and Best-Practice StrategiesThe root
causewas identified as patient related factors. Addressing these factors requires the facility
to administer a standardized fall risk assessment toolat admission to collect information
that helps with developing an individualized care plan. It asks key questions so that the
typical risk factors are identified.Root-Cause Analysis and Safety Improvement Plan. This is
important in helping medical personnel effectively identify patients at high risk of
experiencing falls. In fact, the assessment tool is important for four reasons. Firstly, it
facilitates communication between care settings and medical personnel through presenting
a common language for describing risk. Secondly, it facilitates care planning through focus
on specific dimensions that place the patient at greater risk of fall. Thirdly, it allows for
targeted preventive interventions that makes good use of the available resources to achieve
the most benefit. Finally, it aids in decision-making through ensuring that key factors are
identified and acted upon. The key risk factors that form part of the assessment include
continence, mental status, medication, mobility and use of assistive devices, history of falls,
vision, and gait (Vincent & Amalberti, 2016).Root-Cause Analysis and Safety Improvement
Plan.In addition to the mentioned strategies, the facility should implement a universal fall
precaution approaches that applies to all patients regardless of fall risk. These approaches

4. focus on ensuring that the care environment is comfortable and safe. This includes
following safe patient handling practices, cleaning spills promptly even as floor surfaces are
kept clean and dry, having study handrails in patient areas, providing non-slip footwear,
and familiarizing the patient with the unit environment (Williams, Malani & Wesorick,
2013). Applying the fall prevention approaches are important because they not only
safeguard the patients but also medical personnel and visitors through maintaining a
comfortable and safe environment. Failing to implement these approaches would not only
place patients at risk of falls, but would also place medical personnel and visitors at risk of
falls. These measures should be documented in rounding notes and carefully integrated into
workflow to ensure that they are diligently implemented (Graban, 2018).Existing
Organizational Resources There are existing organizational resources that will help
improve the implementation of the plan. The first resource is the facility administration and
top managers who determine facility policies and operating procedures. They are required
to offer leadership support by approving the plan and supporting its implementation as a
new facility policy. In addition, the help to remove implementation barriers across
departments and authorize resources for use (Hickey & Kritek, 2012). The second resource
is middle managers, medical personnel and support staff who are involved at the unit
level.Root-Cause Analysis and Safety Improvement Plan. They are responsible for realizing
the plan through actualizing its components such as administering the standardized fall risk
assessment tool, ensuring patients wear non-slip footwear and ensuring that floors are dry.
The third resource is the unit champions. They are responsible evaluating the performance
of the plan and gathering feedback. The fourth resource is the implementation team that is
responsible for evaluating data related to the plan’s performance to include tracking
assessment changes and incidence rates before suggesting improvements (Hickey & Kritek,
2012).Root-Cause Analysis and Safety Improvement Plan.