Running Head: RISK MANAGEMENT ANALYSIS
1
RISK MANAGEMENT ANALYSIS 2
RISK MANAGEMENT ANALYSIS
Strayer University
HAS 515
Dr. Chad Moretz
05/09/2020
Risk management analysis
Introduction
Patients experiencing falls while in a health care setting are
largely preventable risks, and many health care facilities have
implemented compliance and risk management plan to minimize
the chance of a fall occurring by any hospitalized individual.
Compliance and risk management plans are implemented to
prevent an occurrence of something that has identified
precursors and can be avoided in most cases if they are adhered
and implemented. This paper will identify a particular
institution's fall risk management plan and compare it with the

corresponding risk management plan of a federal institution
intended to provide plans to hospitals and facilities nationwide
to continue to provide evidence-based practices in prevention of
patient falls. This institution, Hahnemann University Hospital,
will present as an institution that follows the federal regulations
and standards in regards to fall prevention risk management, as
their plan closely resembles that of a nationwide accrediting
agency's standards and more.
The risk management plan chosen is the Falls Prevention
and Resource plan from Hahnemann University Hospital. This
plan is lengthy and very considerate of the federal and state
mandates about this aspect of health care risk management. It
includes the purpose of the plan, definitions and risk factors to
falls, followed by the policy of the hospital and the procedures
in regards to prevention, actions in the case of a fall, and the
post-fall care of the patient, as well as who to notify and who to
send reports of the fall to (Hahnemann University Hospital,
2013). This facility is a large hospital with over 400 patient
beds, numerous staff, and serves a large population of younger
adults due to its university affiliation. The purpose of risk
management in a hospital setting is to set standards for all
employees to work by and to educate the employees on patient
safety policies and procedures if patient safety is not
maintained.
“Fall related injuries occur in 15% to 50% of the patients,
including major injuries such as fractures or lacerations in 1%
to 10%” (Schwendimann, Buhler, et al.) Falls are a nearly
entirely preventable issue in all hospitals that cause a huge
liability risk for hospitals, as well as injury and suffering for
the patients who experience falls while being admitted in
hospitals worldwide. One thing that not many have implemented
is asking the staff what their current knowledge of fall risk and
importance of preventing falls is. Although the Hahnemann
University Hospital’s fall risk prevention plan meets all local,
state, and federal guidelines, adding additional measures to
prevent falls would further decrease the occurrence.

According to Elderly Falls Prevention Legislation and
Statutes, 2018, is planned for the falls among elderly American
people aged over 65 years; that one among the four elderly
adults fall during the year. That statistic is staggering and only
accounts for those over the age of 65. The Joint Commission is
an agency that surveys and provides accreditation to health care
facilities nationwide-with this accreditation; the facility is then
stating that they are following a specific set of evidence-based
standard practices that encourage the highest levels of patient
safety, including inpatient, falls. Some of these rules and
procedures created by The Joint Commission, such as the health
care organization evaluating the patient’s possibility of falls,
and effecting interventions to prevent falls from evaluation of
risks of patients of falling. Individuals in the hospital needed to
follow with the standards stated in the Hahnemann Risk
Management Falls Prevention and Resource manual for
Hahnemann University Hospital. In addition to these standard
risk assessment protocols stated by The Joint Commission,
Hahnemann University Hospital has included multiple
additional steps in both prevention and the handling after a fall
incident, to add to patient safety protocols (Sentinel Event Alert
#55:Preventing falls and fall-related injuries in health care
facilities).
According to study of Pozgar, 2014, he argued that a risk-
management platform aimed to diminish the number of patient
injuries and injury precursors in the health organization and
reduce lawsuits taken against the organization. Risk
management programs are composed of both national standards
by federal and state agencies, accrediting agencies, and
individual hospital staff based on the patient population they
serve. In the US, hospitals are monitored by their accrediting
agencies, ensuring that the hospital follows standards of
practice that maintain patient safety at an acceptable level based
on research and evidence-based practice gathered from many
institutions nationwide. Although falls may not be able to be
entirely prevented, maintaining standards of practice based on a

risk management program could still help. The falls cannot be
prevented 100% but their occurrence rate can be minimized. If
this is not possible the outcomes of falls such as injury can be
reduced or minimized (Oliver, 2007). With this in mind,
certifying agencies like The Centers for Medicare Services and
The Joint Commission routinely survey facilities they've given
accreditation to, to ensure that these facilities are practicing
within their set of standard patient safety measures regularly. If
a facility does not do this, they face suspension of their
accreditation, probation with intent to fix the problem, or even
full surrender of their accreditation. Losing their status with
these accrediting agencies could mean loss of payment for
services by Medicare/Medicaid, loss of government funding,
and potentially, bankruptcy and closure. However, these risks
are worth it when compared to ensuring the patients being
treated are safe from trips, slips, and falls that could cause
injury or death (Oliver, 2007).
The Hahnemann University Hospital's fall risk assessment
management plan is above beyond the requirements of the state,
federal, and other agencies. It covers all aspects of patient
safety in regard to fall risks, and fall risk mitigation. There is
only a few items that could be of value to their fall risk plan, as
viewed on the article of Agency for Healthcare Research and
Quality's (AHRQ) Preventing Falls in Hospitals Roadmap
(Roadmap, 2013) that Hahnemann could make use of. One of
these items is "Determine staff knowledge about fall
prevention" (Roadmap, 2013). This is something often
overlooked, something in the foundation of fall risk
precautions, but vital to the education and understanding of the
staff nurses and aides. Knowing what your staff knows gives a
facility or supervisor a place to start with fall risk education,
instead of assuming every staff member needs to start at the
same place. Another item is setting up goals for enhancement
based on consequences (Roadmap, 2013). It gives a facility a

way to measure progress and ensure change is taking place in a
vital area.
The Hahnemann University Hospital should implement new
regular routine assess knowledge of nurses and precautions
implemented on falls risks managements. The overall staff of
the hospital should adopt these changes to avoid individual
injuries can results from falls. (Stenberg, Wann-Hanssen, 2011)
(CPG=Clinical Practice Guideline). The changes
implementations should be monitored monthly and any issue
should be handled by relevant staff before they become
dominant in the health organization. The regulations and
measures to deal will falls in health care, should be reviewed in
a year to ensure they are effective. Housekeepers should have
plans to prevent falls that results from slippery from slippery
floors.
Risk management programs or plans are an incredibly valuable
tool in the health care industry to promote patient safety and
adherence to standards of care. In any health care facility, the
patient falls a colossal problem that, although they may not be
able to be entirely prevented, have many accrediting agencies.
Both federal and state agencies with a risk management plan to
ensure that dangerous falls that result in injury or even death
are as prevented as can be, for the safety of the patient
population they treat. In this paper, a particular hospital's risk
management plan for patient falls was identified, analyzed,
compared, and evaluated based on the accrediting agencies,
national, and state agencies standards set forth for managing the
risk of patient falls in a healthcare setting.
Conclusion
This institution, Hahnemann University Hospital, had a very
comprehensive risk management plan for patient fall risk and
not only complied with all required standards but achieved
above-said standards, ensuring that their patient population was
as safe from falls as could be. The risk plan identifies all

predispositions to fall of individuals and proper measures are
taken to eliminate the risks of falls in the organization.
References
Hahnemann University Hospital Policy. (2013). Retrieved from
http://essentialhospitals.org/wp-
content/uploads/2013/11/Hahnemann_falls_policy.pdf
Oliver D. (2007). Preventing falls and fall injuries in hospital: a
major risk management challenge. Clinical Risk, 13(5), 173–
178. Retrieved from https://search-ebscohost-
com.lopes.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=1
05946050&site=eds- live&scope=site
Pozgar, G. D. (2014). Legal and Ethical Essentials of Health
Care Administration (2nd ed.).
Roadmap. (2013, January 31). Retrieved October 5, 2019, from
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolk
it/fallpxtkmap.html.
Sentinel Event Alert #55: Preventing falls and fall-related
injuries in health care facilities. (n.d.).
Retrieved from
https://www.jointcommission.org/assets/1/6/SEA_55add_falls_r
equirements.pdf