Hey Liz, I'm Melinda, I'm the Patient Safety Officer for the hospital. I heard that Mr. Frazier fell, and I'm here to find out a little bit more about that so we can learn from him make our systems better. Okay. So, why don't you tell me a little bit about what happened to Mr. Frazier and maybe what led to his fall. Yes. So, Mr. Frazier came from the pack you last night. He was recovering from a hernia repair. I believe he fell around 6 p.m. or so. I had already been on the shift for about ten hours at that point, and the call bells were just ringing, and just it was hard to prioritize at that time where to get to. What else was happening at the same time that Mr. Frazier was on the unit? Well, I went into his room and we found him on the ground along with his I.V. pole. His side rail was down, his table was pushed to the side, so, unfortunately I just didn't get there fast enough. So at the same time, I was busy with five other patients. I was trying to get their meds to them and on time, you know, that's really important. The call bells were just ringing. It was really hard to prioritize and that's why we had a lot of turnover on our unit lately. It sounds like it was a really stressful shift. Is that typical? What was the management's response when he talked to you about these things? Yeah, I mean unfortunately situations like this especially with patients like Chris Frazier, this isn't a typical. We've voiced our concerns to our management and they really just seem indifferent about it. It's really inappropriate for us to delay admissions just because of safety concerns. So, we're kind of limited there even though we try. So. Yes a l of of times they say that, you know, when you hold a patient outside the unit, then there's risk there too. Right. So we're holding up the OR so, management is just about getting the patients in, and we have a lot going on in our unit. What do you think we can do to help you be more effective and create a safer environment for other patients? I really wish that we had some clean tech support. Okay. So, you know, sometimes patients just want a warm blanket, a glass of water, or just help to the bathroom and, you know, when we have to have medications to another patient, that's something a clean tech could really help. That's a great idea. Anything else? I mean five patients, it's a lot. So, you know, many of them just been transferred from the pack you, they are still recovering from the anesthesia. They're very drowsy. So, just having that extra support to help these patients and, you know, maybe a better handoff between nurses, we don't always get that the patients still, you know, a little wobbly on their feet. So, that would really be beneficial. Do you feel like there's good teamwork on the unit? I think we all try. But when we each have five patients and then we have travel nurses, you know, we find unfortunately the travel nurses are not as, you know, into the team, there's no real dedication there and I don't know what their orientation. Its like when they come here, I don't know what they were told about the teamwork and answering call bells, but, we try but it is hard. Great. Are there any tools or any technology you think we could use to make care safer or prevent falls in the future on your unit? All of our beds do have the bell alarms, but when you get an admission real quick, you're just trying to get vitals, make sure the patient's okay. And sometimes you run out the room and you forget to set it. The travel nurses don't always know how to operate our beds so, it's helpful but it's not always utilized the way it should be. Got you. Yes, and you can forget. If you could do things differently with Mr. Frazier, what would you do differently? I really would have made sure I put the bed alarm when I would have made sure that I explain to the patient that you know, you just got out of the pack you, you just had surgery, you are recovering from anesthesia. So, you know, please call if you need help, even if it takes us a little bit of time, we don't want you getting by yourself. I would have made sure that the call bell was definitely in reach and he knew how to work everything. Yes and I would have made sure that I.V. poll was easily accessible for him. Are there any other issues that you want to discuss that might make a difference for your patient falls in this area? You know, going back to getting a better bedside report, I really wish the management would maybe talk to the managers or our nurses, or the park you nurses and let them know that sometimes we're really busy and that getting a patient and very quickly isn't always the safest option. You know, I really wish that there was a better report if the patient is still recovering and now every patients is going to handle anesthesia differently. So, just giving us more information on that, you know, our patient population sometimes can be a challenge as well. Not everyone understands, if you try to give them a hand out about what to expect, they might not be able to, you know, their literacy, they might not understand, they might not be able to read, they might not speak English. So, just if we had extra support and people help with that time then that would just be beneficial for all of us. For the patients that don't speak English, well, do you feel like you have the resources you need to have good translation? No. We just don't have the time. You know, we have the options available but it's hard when you've got the five carbles going off to call the translation and say, hey can I get someone over here? Can I get a translator here? Even to do it through the phone, it takes time and then someone else is being neglected. Okay. I really appreciate your time Liz. You know, we're really trying to figure out how as a team we can learn to prevent these falls in the future. So, your input is really valuable. Thanks. Yes, no problem.
