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FP6016__Assessment1_1.docx FP6016 Adverse Event Analysis Capella University Quality Im

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FP6016__Assessment1_1.docx FP6016 Adverse Event Analysis Capella University Quality Improvement of Interprofessional Care Analyzing an Adverse Event Falls are an issue that affects all health ca... re systems. According to the Joint Commission Center for Transforming Healthcare, hundreds of thousands of falls happen each year in acute care health settings (Joint Commission Center for Transforming Healthcare, n.d.). These falls can add over 14,000 dollars to each hospital stay in which a patient sustains a fall. A fall that occurred at my health care system on the cardiac step-down unit resulted in injury and patient death. The patient was a 70-year-old man who was on anticoagulation for his atrial fibrillation. The patient was alert and oriented, was able to follow instructions, had not fallen in the last year, and did not use an assistive device at home. The patient was scored as a medium fall risk. The patient was assisted to the bathroom and onto the toilet by a patient care technician (PCT). The patient was provided his bathroom pullcord and instructed not to attempt to get up by himself. The PCT closed the door and waited outside the bathroom to provide the patient privacy and dignity. The patient finished in the bathroom and fell while attempting to rise from the toilet independently. The patient did not pull the pullcord. The patient struck his head against the sink and sustained a laceration with a hematoma on his scalp. The patient went to a stat CT scan, which did not show any bleeding. H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . [Show More]

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