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June Case Study

June's fall was largely due to a lack of risk assessment and preventative measures in her care facility, where falls are significantly more common among residents. Care staff often believe falls are unavoidable, leading to negligence that can result in serious injuries or death, particularly for older adults. Improving healthcare quality through understanding human factors and addressing systemic challenges is essential to prevent such incidents in the future.

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Ivel Levi
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2 views

June Case Study

June's fall was largely due to a lack of risk assessment and preventative measures in her care facility, where falls are significantly more common among residents. Care staff often believe falls are unavoidable, leading to negligence that can result in serious injuries or death, particularly for older adults. Improving healthcare quality through understanding human factors and addressing systemic challenges is essential to prevent such incidents in the future.

Uploaded by

Ivel Levi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Involvement

One of the main reasons for June’s accident was that no one assessed her risk of falling or took
steps to prevent it. This is important because falls are very common among older people living
in long-term care facilities (Close & Lord, 2022; Reis da Silva, 2023). In fact, people in care
homes are three times more likely to fall than those living in their own homes. They also face a
ten times higher risk of serious injuries like fractures or brain injuries (Department of Health,
2009). Since this has been known for a long time, care providers should be aware and take
steps to prevent falls (Salari et al., 2022). However, research shows that some care staff believe
falls are unavoidable in care homes. This mindset can lead to carelessness and a failure to take
actions that could keep residents like June safe (Reis da Silva, 2023).

Carelessness in fall prevention can also lead to serious consequences, including death. Studies
show that 70 out of every 100,000 falls result in death, and between 3% to 12% of people who
suffer a fall die within 30 days (Crane et al., 2024; Hamilton et al., 2024). The risk of dying from
a fall increases with age, with people over 80 facing the worst outcomes (Soomar & Dhalla,
2023). However, most falls can be prevented if healthcare providers stay alert and use proven
methods to assess and manage fall risks (Reis da Silva, 2023). There are several reliable tools
designed to assess fall risks in older adults living in care homes, and if one had been used for
June, her accident might have been avoided (Strini et al., 2021).

Several human-related events combined to produce June's fall by causing insufficient patient
awareness and care. Research indicates "Human factors" describe covert healthcare team
elements which affect their decision-making along with their actions resulting at times in patient
injuries (Brennan & Oeppen, 2022). User behavior together with human interaction dynamics
and environmental responses form the basis of this research subject (National Health Service
England, 2013). Research indicates that enhancing healthcare quality through human factor
improvements leads to better patient security together with decreased older adult fall incidents
(Brennan & Oeppen, 2022; Hignett & Wolf, 2016; Kwok & Lam, 2022). Understanding June's
environmental and personal factors will help healthcare providers determine the reasons behind
her fall incident along with designing suitable prevention measures. Multiple fall prevention
approaches are necessary yet fail because healthcare institutions lack proper staff, experience
high patient numbers, face facility inadequacies and have insufficient necessary supplies (Kwok
& Lam, 2022).

In June’s case, the nurse treating her wound assumed that the primary care team would check
on her soon, which led to inaction. Instead of taking steps like directly contacting the primary
care team or following up on her condition, the nurse did nothing. Because of this, the nursing
home staff also did not take further action, as they believed the primary care team would handle
June’s case. This resulted in a lack of responsibility, where everyone assumed someone else
would act but no one did.

However, it is important to acknowledge that healthcare teams often struggle to provide timely
care due to limited resources and high patient demand, especially in systems like the NHS
(Mahase, 2021). Even if the nurse had followed up, delays could still have occurred due to
system-wide challenges, which may have contributed to a lack of urgency in addressing June’s
needs.

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