Type your introduction here. Briefly describe the setting, the
patient safety issue or sentinel event, and its significance.

Focus will be on High risk fall patients in the emergency room
setting

Describe what happened, who was affected, and the actual or potential
outcomes of the event.

Patient with altered mental status brought to emergency room for
evaluation. Patient presents to be high fall risk due to being unaware of surroundings,  poor judgement, ..

Patient assessment on calculated patient as low fall risk

Nursing judgement assessed patient as high fall risk but
documentation using John Hopkins fall risk assessment analyzed patient as low
fall risk

Bed alarm was not activated and fall risk alert armband was not
applied.

Hospital transporter transported patient via stretcher to pending
diagnostic scan without awareness of patient high fall risk status and
unaccompanied by primary nurse or patient technician.

Patient was left unattended while awaiting transport to return to the
emergency room after diagnostic scan was completed 

During wait time patient attempted to get out bed and fell

Identify and analyze the primary root cause(s) and contributing
factors. Discuss human, system, policy, and organizational influences and
their degree of contribution.

The John Hopkins assessment tool does not have the option to input
nursing judgement questions to generate a true patient assessment

Fall risk prevention tools were not implemented

Hospital policy does not state transporters must remain with patient
unless specifically requested

Clearly list the root cause(s) and summarize associated contributing
factors. Include relevant categories such as communication, training,
environment, or policy.

Summarize current scholarly evidence related to this safety issue and
explain how these strategies apply to preventing recurrence in this setting.

Describe specific, feasible actions to address each root cause. Note
whether risks are eliminated, controlled, or accepted (E/C/A).

Explain new or revised processes, education or training plans,
implementation timelines, and desired outcomes.

Identify and prioritize existing organizational resources that will
support successful implementation of the safety improvement plan.

Non slip yellow socks

Red Fall risk armbands

Secured bed rails

Bed alarms

Sit to stand device

Patient sitters

Summarize key findings, restate the importance of the safety
improvement plan, and note anticipated impacts on patient safety and quality
of care.

List all references here in correct APA 7th edition format.