Injuries occurred due to fall are one of the common causes of the activities that are restricted and due to the disability of the older adult populations (Alhawassi eta al. 2014). Fall is a result of the combinations of trauma and old age. It has been reported that about one third of the population who are above 65 years of age fall at least once in a year (Al Saif, Waly and Alsenany 2012). The high rate of incidence and the severity of the complication related to fall increase with the age, disability rate and the impairment of the functions. There has been a recognition of the personal and the social effects of fall at the national level all over the world, therefore objectives have been undertaken for improving the conditions and implementing developments in respect to the present scenario (American Occupational Therapy Association 2015).
There are various fall risk factors that is associated with the fall in older adults. These factors are mostly classified as the intrinsic or extrinsic factors that tend to vary in relation to the group of and the situational setting such as it can be the community or the hospital setting. Falls are generally the consequences of multiple, varied and interacting risk factors which requires a multifactorial approach for the fall assessment and intervention that is required by most populations (Dekker 2017). The factors that are present in the intrinsic factors contain the factors of muscle strength impairment, reduced balance, gait and cognition. Additional factors includes vision, symptoms of depression and fear of falling along with postural hypotension, arthritis and the administration of prescribed medications or the benzodiazepines. The factors which are extrinsic are environmental in nature. Most of the falls generally occur near the home hence consideration of the hazards near and around the home is required. The identified fall hazards are presence of slippery surfaces, several obstacles in pathways and insufficient illumination (Donnelly 2013).
The guidelines developed for promoting fall prevention needs to be carefully evaluated related to the risks of the individuals and their deficits. There is also a need to consider the interaction and the synergy that is present between the various risk factors. A useful framework for this purpose is provided by the Person–Environment–Occupation (PEO) model that is used to evaluate the risk of fall (Fisher 2014). The major adaptations of the model includes the person , the environmental conditions and the interaction of the occupations together with the time period and space in a way that leads to increase and decrease of the effects. Occupational performance can be increased in respect to fall prevention with the focus on the reduction of the risk of fall along with the increase of the client’s dignity and confidence in order to take part in the activities without the fear of falling.
The term human error reflects the factor that is mainly responsible for the number of accidents and the mishappenings that takes place. Therefore this can be explained as the derailment form the original intentions and the desirability of the expectations (Hildenbrand and Lamb 2013). It is seen that humans are prone to making mistakes in both personal and professional aspects hence this is the same in case of health care of healthcare professionals. The incidents of the accidents are not due to the consequence of a single incidence but occurs due to the number of actions that fails in the system as a whole. Human errors can be clarified along with the defences when there is a recognition of the hazards this can be effectively carried out using the Swiss Cheese Model (SCM) (Karlsson et al. 2013). This model provides an efficient tool for carrying out such assessments. This can efficiently detect and focus on the individuals who is actually responsible for committing the alleged action. SCM is involved in promoting the analysis of all surrounding factors that has led to the occurrence of the incident. Example can be seen in the case of occupational therapists or the nurses who are responsible for administering an overdose to a patient, where the Swiss Cheese Model (SCM) implements an investigator in order to explore the actions instead of only the cause. There are two types of failures according to the model such as active and latent failures (Laliberté et al. 2013). The active failures are committed by the person who do their duty and are at the dead end of the system that they belong to whereas in case of the latent conditions, the main contributing factor in the entire system can occur upstream at one or more remote layers which is known as the blunt ends (NICE 2018).
This paper aims to illustrate the practise errors in humans that is mainly caused to the inexperience of practise along with the lack of skills especially among the occupational therapists. The paper is mainly explained in terms of the healthcare settings. This study helps to highlight the influence of the risk factors that influences the fall in the older adults. The paper also discusses the probable reasons of the fall along with the implication of the practise that prevails in the clinical settings. The paper thrives to highlight the practise errors of the occupational therapists and makes attempts to suggest recommendations which will help in betterment of the practises and to improve the quality of care in future.
Narrative review of literature
A study conducted in order to identify the factors related to fall showed that there is a strong relation between age and the increasing risk of fall (Whalley Hammell 2013). There were also other studies that have established this fact and have added that along with age, the problems of gait that increases with age has caused increase in the rate of falls. There was another study that have shown that in the hospitals of Saudi Arabia there is an increasing rate of accidents especially in the group of individuals who are above 60 years or more. Previous literature have suggested that more than one third of the individuals who are in the age group of 65 or above shows risk of falling in an annual rate (Yunqui and Thimbleby 2014). Studies by Underwood and Waterson (2014), stated that with the increase in age there are incidences of falls that is seen to increase in the individuals who show functional impairment and suffer from some kind of disability and is more prevalent in the age group of individuals around 90 years of age. Studies have also suggested that there is a relation between psychological ageing and the incidences of reduction in the amount of reaction time of an individual along with the deterioration in sensory acuity and the muscle strength leading to decrease in balance in the older adult population in Saudi Arabia. There is an established relationship between the muscle strength and age along with the ability to function properly. Therefore this suggested that falls might occur due to the increasing age leading to gradual decrease in the strength of the muscles and the ability to function. Therefore the study successfully established the scenario that for individuals above 60 years of age there is mainly a risk of fall due to the depleting health conditions of these individuals. In Saudi Arabia there is an indication of increasing fall rate due to the decrease of balance ability (Upton et al. 2014). Literature also showed that age is directly related to the decreasing amount of muscle strength and the mass of the muscles, which ultimately leads to the accidental falls mainly as a result of frailty in physical terms along with mobility impairment and decreased functional capacity. A study conducted on this group of affected individuals confirmed that these older adults of Saudi Arabia show very less amount of physical activity which in turn increases their chances of disability hence affecting the mobility and performance of the basic actions in daily life. Functional independence is lost as a consequence of this hence suggesting that in order to promote fall prevention it is important to make a shift form the sedentary lifestyle to an active lifestyle.
The situation portrays Mr. John who has been suffering from gait abnormality for a long time now. He is 65 years and has decreased functional ability of the muscles leading to impairment in mobility. This paper highlights the working of an occupational therapist which such patients in a hospital setting in order to provide such individuals who have decreased movement abilities to provide quality healthcare. The main role of the occupational therapist was to assist the patient during his basic activities like going to the bathroom and eating food and other such activities. The major role which these occupational therapists play lead to improvement in the overall physical well-being of the patient. The condition which Mr. John has been suffering from was partly result of a minor stroke that had occurred few years back, making his muscles loose vigilant functions thus impairing his physical movements. However with increasing age, there has been deterioration in his functional conditions hence now every time he needed assistance for movement, or it would increase the risk of fall. The OT commenced her duty by helping the patient to stand upright and assisting her to move towards the bathroom. At first the patient was hesitant to move forward without his walking stick. The OT assured him that he could manage it without the stick. However before reaching the toilet the patient had an accidental fall inspite of the OT being there to assist. The outcome of the injury was severe and the patient had an injury in the hip region which worsened his conditions. Not only the fall had an impact on the physical conditions of the patient but also impacted him mentally, causing a sense of fear and loss of confidence. The family members of the patient were utterly disappointed with the whole situation and presented allegations towards the OT who was in charge of the patient. Investigations were conducted on the whole situation which reflected that inspite of the fact that the patient had difficulty in walking the OT had not been careful enough and had left the patient when he no more could hold up his balance and had fallen down.
Conceptual model of the situation
The scenario that is discussed above portrays the fact that for improving the conditions of fall major focus has to be shifted towards the improvement of the medical conditions especially in the hospital setting where care is provided by the occupational therapists. Most of the patients who are admitted in the hospital wards have been suffering from serious health issues hence they are needed to be given proper care. In order to identify the factors that lead to the major incidences of fall and such accidents several analysis tools are used. The following part describes the factors that have caused the fall in case of Mr. John.
Analysis of the factors of Fishbone Model
The environmental factors are components of high intensity interventions which tend to use approaches that are comprehensive and validated by the assessments. These targeted individuals are at high risks and the occupational therapists are involved in the process. Individuals who were suffering from severe impairment of vision can be highly benefitted from the interventions that are carried out in the home setting and involves home safety interventions which provide customised needs to the patients (Thomas and Law 2013). Another component is adherence. Safety recommendations have shown adherence to the occupational therapy, where the patients are of the belief that modification of the home can provide suitable measures to inhibit the rate of fall. Interventions can be carried out to develop mobility skills that help in improving the balance and provide vital components to an approach for preventing falls. These interventions can help the individuals of the older ages to increase the power of the muscles and improve balance (Taylor 2017). Balance training provides postural control by several activities. It is the duty of the occupational therapists to understand the problems can properly carry out these interventions in order to provide better support and care. This will also increase the self-monitoring abilities of the individuals and help them to incorporate exercise in their daily lives. There can also be several group based interventions that can be carried out in the community dwelling older adults. These interventions although should be monitored by an interdisciplinary team, however major input should be received from the occupational therapists. Example of such an intervention is matter of balance that was developed by an interdisciplinary team at the University of Boston (Sturkenboom et al. 2014).
Occupational therapy under the context of fall prevention
For the older adults who are at the verge of the risk of falling or have already experienced an accidental fall in various settings of health, social care, independent sectors which includes hospitals and personal homes. Additionally it can be care homes, day centres and prisons where the individuals need to undergo occupational therapy interventions. For conduction of such interventions of occupational therapy there are certain guidelines that are needed to be followed (Schell et al. 2013). The major purpose of the occupational therapy is the provision of support of practical nature to the individuals in order to help them to defy the barriers that come in their way related to the activities that are needed to be carried out on a daily basis. Support from the occupational therapists helps in gaining independence of physical functions and helps to maintain their confidence and satisfaction in their lives. The term occupation reflects the practical activities that are carried out so that the people can achieve their desires and meet their needs. This could include the daily activities which are quite basic like the activities that are related to work or it could be leisure activities and hobbies. There is a requirement for implementation of clinical reasoning that addresses the complexities of the individuals in terms of treatment and multiple pathologies (Roberts and Robinson 2014). There is also a provision for the people suffering from disorders like dementia and learning disabilities along with other emotional and cognitive disorders. People designated as occupational therapists should consider the dimensions of intrinsic (person), extrinsic (environment) and behavioural (occupation), in order to acknowledge the risk of falls (Scaffa and Reitz 2013). By acknowledgement of these dimensions the quality of the interventions can be improved and it can have a positive impact on the person’s ability to conduct the basic activities on a daily basis which can be termed as the occupational performance.
Analysis of the factors associated with occupational therapists
The people who are risk are generally identified as the individuals who are the older adults. When they come in contact with the healthcare professionals especially the occupational therapists they must be inquired about any past incidences of fall which they might have experienced. Additionally the frequency and the context of the fall must be noted down along with the characteristics of the fall. In case of situations like falls, osteoporosis and other such fractures that are linked to one another, it is the duty of the occupational therapists to be aware of the groups who are mainly at increased risks (Pendleton and Schultz-Krohn 2017). Care should be given to their diets, conditions if physical activities and administration of medications. The occupational therapists tend to work with patients suffering from all conditions like the people suffering from Parkinson’s disease who at most times are at the risk of falling due to the due to problems of postural instability and balance impairment. Additional problems include decrease in saving reactions, disturbances in visuals and decrease in tasking abilities (Kwan and Straus 2014). Often the patient with limb amputations and those who have undergone total hip replacement are also included. Therefore is highly required by the occupational therapist to be able to recognise the individual’s risk factors for falls, including those factors that may and may not be altered.
Analysis of the surrounding environmental condition
The surrounding environmental conditions that can be taken into account for improvement of the occupational therapy related to the risk of fall in older adults includes various approaches along with its special characteristics as is described in the following: the first approach that should be taken into account includes how the person fits with the environment. The characteristics of this approach includes ladder safety and climbing alternatives that are best suited for a person who is active. There might be tripping hazards which is more relevant o the individuals who is frailer in nature (Hudon et al. 2014). The next is the understanding of the clients’ fall experiences and interpreting the client’s beliefs about causes of falls. This challenges the patient to highlight their risks and helps to understand the causes that are important for causing the fall. A problem solving approach should be undertaken that will help in auditing the home simultaneously with the client in order to address the concerns of behavioural and environmental nature. This will in turn help to develop the priorities. There is a requirement for interpreting the meaning of home, the activities associated along with the sense of control. For this understanding the activity in the context of the client is highly required. Risk-taking behaviours should be adapted along with the encouragement of adaptations of protective nature. In such cases situational cues are required and there might be a need to change the target of the behaviour (Hildenbrand and Lamb 2013). Often up-to-date knowledge is necessary which provides options for critical hazards that are frequently related to falls. There is a need for being knowledgeable especially regarding the products which are slip-resistant. Strategies are needed in order to fix loose floor coverings and development of new safety products. Environmental redesign strategies might be implemented which might involve removal or relocation (Fisher 2014). Awareness should be encouraged for the raising and generalization to other situations which can be done by safe behaviours in a wide range. Safe mobility strategies might be assessed and practised. The occupational therapists need to encourage the proper kind of exercise and physical activity and attempt must be made for the incorporation of exercises and activities into daily life routines especially in safe ways.
Analysis of the organisational management and strategic factors
Strategic factors that can be implemented in the organization level mainly includes the interventions that are carried out in the medical settings. There is a requirement for the promotions for carrying out physical exercises on a regular basis which included balancing and strength training. Aerobic exercise of low impact, body flexibility exercises and functional exercise along with the health promotion in the workplace which forms a major part of the interventions. There must be awareness of muscle strength loss and endurance was also reported which might occur by the age of 50 (Fawcett 2013). It is seen that the person who possess lean body tissue have chances of higher percentage of lower bone density and fat in the body. Weakness in the muscles of these individuals who are in the advanced age group lead a sedentary lifestyle which place them in a more risky condition. There are other conditions related to the social and physical and psychological terms. This especially occurs in conditions of isolation, impairment of cognitive functions, mobility impairment and decrease in quality of life among older adults. Therefore strategies must be implemented by the organizational managers to implement training exercises following a regime of 8-10 muscle groups using 8-15 repetitions of each exercise for 2-3 days per week (Clark and Schlabach 2013). Management must also be conducted in terms of administration of medications. Assisting devices might be used in such cases. Studies have shown that use of improper medications in elderly people have increased the risk of falls. Often consumption of benzodiazepines for prolonged periods was responsible for the increase in the risk of falls. Therefore strategies must be implied in order to inhibit the elevated risk of falling (Cho, Yu and Rhee 2015). Side-effects are shown in case of use of inappropriate drugs for the elderly that has contributed to the risk of falling mainly due to the causes of drowsiness, reduction in postural reflexes along with extrapyramidal symptoms caused by over drugging and myorelaxant effect (Dekker 2017). There is an increase the severity of these side effects due to the chances of age-related changes in drug metabolism and polypharmacy. This in turn can heighten the risk of falls. Therefore care should be for proper medication to avoid inappropriate dosages, adverse drug reactions, omissions, incorrect administration of medications, and incorrect administration of medications, present "risks" and increase patient accidents for falling in hospital (Cahill et al. 2014).
Active/latent failure and unintended consequences of practice problems
Studies conducted by (Alhawassi et al. 2014), have shown that there are various underlying factors that contributes to the risk of falls which mainly occur in the health care settings. Proper evaluation of the hospitals are required to be carried out especially on a regular basis to make sure that the risk of the patients is recognised, which can be further targeted for providing treatment and strategies of prevention. Studies have recommended that occurrences falls continues to be one of the highest priorities in terms of healthcare policies in most of the healthcare institutions especially for older adults there is a need for more research in order to understand the situations in a better way and find ways to predict the incidences of fall among older patients mainly in the hospital settings (Almegbel et al. 2018). There is a requirement for proper education of the patients so that they are able to interpret the mechanisms of prevention of fall and the risk factors that are associated with it. Assessment of the environmental factors must be conducted that includes sufficient lighting in the corridors and the stairways, installation of the bathroom grab bars next to the toilet and also in the tubs or shower. Placing of non-skid mats in tubs or shower is required along with installation of raised toilet seats. Handrails in the hallways is essential and stair way banisters should be secured. There is a requirement of a proper bed height to reduce falls (Ashby et al. 2013). Arrangement of appropriate physical design of the equipment’s present in the hospital such as patient beds may reduce patient falls and injuries. Rearrangement of the furniture can be made in order to support a patient who is unstable for ambulating to the bathroom. Strategies can be implemented that helps in reducing mobility by using restraints of certain kind that may prevent falls but also attract other problems however such cases must be tried to be avoided (Al Saif, Waly and Alsenany 2012).
Recommendation can be suggested in the several aspects of the occupational therapy that is considered in the study. There are certain guidelines related to the occupational therapy which suggests recommendations having the core theme of keeping safe at home by reducing risk of falls, keeping active by reducing fear of falling and fall management.
Reducing risk of falls by keeping safe at home
Patients who are prone to falling or have already experienced a fall must be offered an assessment for hazards by an occupational therapist. It should involve interventions and a follow-up in order to optimise the functional activity and safety procedures. There must be a provision for home safety assessment and modifications for the older adults by the occupational therapists especially for those who suffer from visual impairment. There is a need for the occupational therapists to conduct a pre- or post-discharge home assessment with the aim to reduce the risk of falls after the discharge from an inpatient rehabilitation facility, considering the service user’s risk of falls, ability to function properly as well as diagnosis. Occupational therapists should take steps to offer services to users who are living in the community based on the assistive devices that are part of a home hazard assessment (Cahill et al. 2014).
Keeping active and reducing the fear of falling
Occupational therapists should take steps to investigate whether fear of falling is seen as a restricting activity for the service users both inside and outside the home. This might include the promotion of occupational activity within the intervention plans that are individualised. There is a need of the occupational therapists to listen to an individual’s views regarding their falls risk, along with using objective functionally based outcomes in order to explore the fear of falling and the influence is has on the client’s daily life. Occupational therapists should look into ways to enable the clients to reduce the risk of falling while they are performing the necessary activities. This might help to elevate the level of confidence in them and promote risk taking that are realistic in nature. Occupational therapists should facilitate caregivers, family and friends to undertake a positive view towards the risk factors (Case-Smith, Clark and Schlabach 2013).
Sharing of knowledge and understanding of falls prevention must be present in the occupational therapists so that management strategies can be provided to the service user. This helps in acquiring personal information that are relevant and considers the individual’s fall risk factors, lifestyle choices and their preferences. Occupational therapists should acknowledge the service user’s views and beliefs in respect to their ability and personal motivations. Thus this may influence participation in the interventions of fall. It is the duty of the occupational therapists to extend their provision of services to the client so that they feel they are under the control of the falls intervention (Fisher 2014). Occupational therapists should support the engagement of the service user in identifying the positive benefits of falls intervention. It is necessary that the information of the falls prevention and management should be available in different formats and languages. This will help to empower and engage all populations from various backgrounds, which includes the web-based support along with the written information leaflets (Hildenbrand and Lamb 2013). Activities of social and physical nature must be conducted for the reduction of an individual’s risk of falls and the negative consequences it has. Encouragement and support is required that is provided through the use of activities pertaining to the perceptions of the individuals. Incorporation of activities like exercises are needed to be implemented into daily activities and occupations that are meaningful to the individual for improving long-term participation in the fall prevention interventions (Hudon et al. 2014).
Recommendations can also be provided in terms of the way the problems can be considered and the direction of the outcomes for the individual evidences that are used to support the interventions. There are also various financial barriers along with the organizational barriers that cannot be compared with the interventions of the occupational therapy. Therefore there is a need of alternative management options so that help is available from the members of an interdisciplinary team. They can help in providing a multifactorial intervention which includes activities such as the strength and balance training including different exercises, assessment of the vision along with referral and review of medications. Recommendations are mainly based on production of the best available evidences. It is therefore required to be noted that the guidelines mentioned are not able to be reflect totally the role of occupational therapists (Kaskutas et al. 2013).
From the above discussions it was evident that in order to reduce the occurrences of human errors, there is a need to understand the nature and the characteristics of the errors by the occupational therapists. The situation that is portrayed has been analysed efficiently using the fish bone model which successfully identifies the risk factors that is associated with falling. Assessment is conducted of the major factors that is related to the incidences of fall in the older adults. The organization along with the government plays a role in the framing of policies and the guidelines for the conduction of practises of the occupational therapists. Analysis of the patient’s conditions and the direct communications or the analysis of the patient’s report and must not rely on their own intuition to take decisions in the therapy plan. Several suggestions of recommendations have been made in the study in respect to the various aspects of the risk of falls like falls management, keeping safe in the home and in respect to keeping safe by avoiding the fear of falling. While conduction of the study consideration was made that the falls among the older adults could be easily avoided if the occupational therapists and the other healthcare professional pay more attention and care in provision of quality medical services and is able to acknowledge the risk factors that bare associated with the fall in these individuals. It was also inferred from the above study that the rate of practise errors might be different for different scenarios. The study can be concluded by mentioning that the rate of fall among older adults can be detrimental to their physical and their mental conditions. Therefore effective analysis of the associated factors will help providing the older adults with better conditions of daily activities.
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