Client Falls and Handling and Transfer Injuries

Injuries caused by falls and handling and transfer incidents can result in significant disabilities with loss of independence and associated costs for clients and visitors. Safety is fostered by both fall prevention strategies and safe client handling and transfer practices, and by reducing the severity of injury should a fall or related injury occur.

Expected Outcomes

Implement standardized, evidence-based falls prevention program, safe client handling and transfer program, and post incident response protocol.

Implement formal strategies to provide targeted falls prevention and safe handling and transfer education and training for staff and clients / families.

Adopt standardized quality indicators to review and monitor the collaborative care process involving client falls and handling and transfer injuries. 

Definitions and Acronyms

• Client – includes all persons who receive healthcare and related services including patients, residents and persons in-care
• Handling – lifting, transferring and repositioning of a client (Ontario Health, 2022)
• MRP – most responsible practitioner, often a midwife, nurse practitioner or physician

Common Claims Themes and Contributing Factors

Organizational

• Perceived or actual systematic tolerance of unprofessional or unsafe behaviours.
• Intra- and inter-disciplinary conflicts.
• Lack of, unrealistic, or ambiguous escalation and chain of command process.
• Insufficient mechanisms to support provider and team proficiency with falls preventions and safe handling and transfer practices.
• Inadequate or lack of organizational client falls prevention and safe handling and transfer programs. 
• Inadequate supply of protective equipment / devices (e.g., hip guards, padded floor mats, bed alarms).
• Inadequate environmental surveillance and prevention of hazards (e.g., wet floors, inadequate lighting, uneven surfaces, sensor activated doors).
• Failure to consider client appropriateness when using unconventional spaces for client care.
• Inability to access care plans in the community and home care settings.
• Human health resource shortages negatively impacting staffing mix and compliment.
• Perceived or actual tolerance of delegating client transfer, mobility, and handling tasks to staff and support workers (including agency/contracted care workers) without adequate and appropriate training, skills, experience, or access to ongoing support.

Equipment and Supplies

• Failure to adhere to preventative maintenance schedules for client mobility equipment (e.g., lifts, walkers, beds) and supplies (e.g., slings).

Knowledge and Judgement

• Normalizing and decreased vigilance over time towards falls prevention and safe handling and transfer best practices.
• Failure to follow policy or adhere to standard of care.
• Inadequate or outdated care plans that no longer reflect the client’s current clinical status (e.g., loss of strength impacting client’s ability to assist with transfers).
• Failure to follow safe transfer and handling and fall prevention care plans (e.g., two person lift).
• Lack of awareness of the organizational or agency client handling and mobility practices.
• Inconsistently completed falls risk assessment and / or reassessment where indicated.
• Inconsistently and / or inadequately performed injury assessment after a fall or handling / transfer incident.

Client Centred Care

• Inconsistent or lack of appropriate education and instructions provided to clients, families, and caregivers regarding falls prevention and safe handling and transfer measures.

Communication

• Hesitancy to and / or significant delays notifying team leads and / or MRP following a client fall and / or handling or transfer incident resulting in potential or actual client harm.
• Hesitancy to escalate concerns about unsafe practices and practitioners, including:
  • Practitioners in leadership roles; 
  • Disagreements with leadership regarding further escalation of unresolved concerns.
• Failure to communicate clients falls risk status or change in status (e.g., falls history, sedation prior to a diagnostic test) during client handovers and transfers of care.
• Inadequate falls risk cues (e.g., arm band, client room signage, health records flag).

Documentation

• Inadequate documentation of risk assessments and care plans.

Mitigation Strategies

Falls Prevention and Safe Handling and Transfer Practices

• Implement an evidence-based falls prevention program (Registered Nurses’ Association of Ontario, 2017) (Ontario Association of Non-Profit Homes and Services for Seniors, 2011) (Agency for Healthcare Research and Quality, 2023).

Additional Considerations

Examples of elements to address within the evidence-based falls prevention program and policies / procedures:

• Standardized definition of a client fall;
• Adoption of standardized ‘universal falls precautions’; 
• Use of a standardized, evidence-based and validated falls risk screening and assessment tool;
• Triggers / criteria for conducting a falls screening and assessment (on admission, post fall, significant change in health status or transitions, etc.);
• Visual client falls risk prompts;
• Conducting medication reviews for polypharmacy and / or drug classifications associated with side effects which may affect balance, cognition, or other factors impacting mobility (e.g., opioids, psychotropics, cardiac medications, hypoglycemic agents);
• Standardized evidence-based and validated client mobility and handling criteria and / or algorithms.

• Ensure congruency between the organization’s fall prevention and restraint minimizing programs and care plans; ensure a discussion and order (where required) with the MRP or primary nurse is required before restraints are applied or removed (Registered Nurses’ Association of Ontario, 2017).
• Implement an evidence-based safe client handling and transfer program (Ontario Association of Non-Profit Homes and Services for Seniors, 2011).
• Implement evidence-based, interdisciplinary, and integrated care pathways for falls prevention, client handling and transfers, and related management; support and expect tailored multifactorial interventions and care plans as required; ensure the care plan is readily available to all involved care providers (Ontario Association of Non-Profit Homes and Services for Seniors, 2011) (Agency for Healthcare Research and Quality, 2017).
• Implement regular rounding for proactive assessment of environmental fall hazards assessments (including in the home health settings where indicated), clients’ falls prevention needs, toileting routines, and anticipating other client needs (Agency for Healthcare Research and Quality, 2017) (Feil & Gardner, 2012) (Health Research & Educational Trust, 2018). 
• Implement strategies to support an adequate and safe level of coverage and support for client handling and transfers during periods of lower staffing levels (Clarke & Donaldson, 2008) (Jessamyn, Malliaris, & Bakerjian, 2021).
• Adopt best practice for delegating or assigning client transfer and mobility-related tasks to unregulated care providers (College of Nurses of Ontario, 2013) (Canadian Nurses Protective Society, 2021) (College of Registered Nurses of Manitoba, 2023).

Safety Culture

• Implement strategies to improve the culture of reporting for client falls and transfer and handling injuries (e.g., just culture approach to feedback, risk identification, and reporting of incidents; approaching near misses and harm incidents as learning opportunities; focus investigations on the problem or process versus the individual) (Health Research & Educational Trust, 2018).
• Implement formal strategies to develop and maintain a work environment which supports and expects:
  • Intra- and inter-professional collaboration and collegiality;
  • Zero tolerance of intra- and inter-disciplinary bullying and intimidation;
  • Assertive and respectful questioning and challenging of unsafe practices;
  • Early response to suspected and actual client falls and handling and transfer incidents, including seeking assistance from peers and other resources. 
• Adopt a standardized, formalized, and program-specific chain of command (escalation) protocol for the rapid escalation of unresolved care concerns or disagreements related to orders, decisions, and / or fall and handling and transfer incidents.

Team Training and Education    

• Implement formal strategies to support and enhance the teams’ clinical knowledge, skills (technical and non-technical), and practical experience, including (but not limited to) scheduled interprofessional and cross-department skill drills and simulations related to (Ministry of Labour, Immigration, Training and Skills Development, 2022) (Canadian Centre for Occupational Health and Safety, 2023):
  • Safe client handling and transfer practices;
  • Use of mechanical lifts and mobility aids;
  • Safe assignment or delegation of client handling and transfer tasks to staff;
  • Safe restraint practices (e.g., steps required to apply or remove restraints);
  • Management of clients with aggressive behaviors or cognitive impairments.
• Ensure the team training and education strategies consider or involve unregulated care providers, support staff, locums, agency, contracted care providers in addition to regulated health professionals (Health Research & Educational Trust, 2018).

Client and Family-Centred Care

• In consultation with client and family advisors, adopt standardized client falls prevention and safe client handling and transfer education, training, and discharge instructions for clients, families, and other care providers (Health Research & Educational Trust, 2018). 
• Implement formal strategies to support and encourage client and family engagement in fall prevention and client handling and transfer planning, rounding and handovers, and escalation of quality or safety concerns, including evenings, nights and weekends (Registered Nurses’ Association of Ontario, 2017) (Health Research & Educational Trust, 2018).
• Implement strategies to enable access to interpreter services during (but not limited to) client and family engagement in fall prevention and client handling and transfer planning, education, training, and discharge.

Equipment, Supplies and Technology    

• Implement formal strategies to ensure (Canadian Centre for Occupational Health and Safety, 2023):
  • A sufficient number and type of functioning falls prevention and detection technologies as well as client handing and transfer equipment (lifts, boards, etc.) based on client acuity and volumes;
  • Equipment such as call bells and bed rails are in proper working order;
  • Client mobility aids and frequently required personal possessions are kept at the bedside and / or within reach.
• Implement formal strategies to ensure scheduled preventive maintenance checks for client mobility equipment and supplies take place in compliance with manufactures’ guidelines (Ministry of Labour, Immigration, Training and Skills Development, 2022).

Incident / Emergency Response

• Adopt a standardized incident response protocol to aid decision making following a client fall or a handling or transfer incident (Agency for Healthcare Research and Quality, 2017).

Additional Considerations

Examples of elements to address within the incident response protocol following a client fall, handling or transfer incident:

•    Offer safety and support, but do not move the client without an understanding of the severity of the harm / injury; conduct a comprehensive assessment; call for help as required;
•    Notify the most responsible practitioner; consider the need to notify the substitute decision maker or family (with consent or as appropriate);
•    Monitor and reassess the client;
•    Document all observations, client / family statements, assessments, notifications, interventions, evaluations, etc.;
•    Complete post-falls screening and assessment with required communication to healthcare team and documentation of same (Agency for Healthcare Research and Quality, 2017);
•    Conduct a post-falls or handling and transfer injury debrief to identify modifiable fall risk and handling and transfer factors; make changes to the client’s care plan as required.

Monitoring and Measurement    

• Adopt a standardized, interdisciplinary, collaborative, and evidence-based protocol for conducting quality of care reviews involving client falls, handling and transfer incidents resulting in patient harm or death (Agency for Healthcare Research and Quality, 2023) (Incident Analysis Collaborating Parties, 2012) (Machen, 2023); incorporate system thinking and human factors concepts into the review process. 
• Adopt standardized quality indicators for client fall prevention and safe client handling and transfers (Registered Nurses’ Association of Ontario, 2017) (Agency for Healthcare Research and Quality, 2023).
• Incorporate learning from local, provincial, and national client falls and handling and transfer incidents and data into local protocols as well as staff, client, and family education and training (Health Research & Educational Trust, 2018).

References

• Agency for Healthcare Research and Quality. (2017). Module 3: Best practices in fall prevention—training guide. Retrieved from https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/guide.html
• Agency for Healthcare Research and Quality. (2023). Preventing falls in hospitals. Retrieved from https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/index.html
• Alberta Health Services. (2020, 2). AHS EMS Dispatch. Retrieved from Alberta Health Services: https://www.albertamfr.ca/data/documents/Response_Plan_Codes.pdf?A78DC3EF-CEFE-417E-A2F6C719298D310D
• Alberta Health Services. (2022, 3). Records Retention Schedule (1133-01_. Retrieved from Alberta Health Services: https://www.albertahealthservices.ca/assets/info/hp/him/if-hp-him-records-retention-schedule.pdf
• Alberta Health Services Emergency Medical Services. (2017, 6). EMS MCI Response Plance. Retrieved from Alberta Health Services: https://www.albertamfr.ca/data/documents/MCI_Response_Plan_(final).pdf
• Bain, T., Al-Khateeb, S., Bhuiya, A., DeMaio , P., Soueida, S., Jarvis, T., . . . Wilson, M. (2022, 8). Rapid synthesis: Identifying approaches to optimal management of ambulance-to-hospital offload processes. Retrieved from https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/identifying-approaches-for-optimal-management-of-ambulance-to-hospital-offload-processes.pdf?sfvrsn=9d809fdb_7
• Basnett, E. (2022). California EMS System Core Quality Measures Report Calendar Year 2021. Retrieved from https://emsa.ca.gov/wp-content/uploads/sites/71/2022/11/CQM-Report-Final-SYS-100-12-2021-Data_11.29.2022.pdf
• BC Emergency Health Services. (2023, 3). A03:Clinical Handover and Communication. Retrieved from https://handbook.bcehs.ca/clinical-practice-guidelines/a-general/a03-clinical-handover-communication/
• Bigham, B., Morrison, L., Maher, J., Brooks, S., Bull, E., Morrison, M., . . . Shojania, K. (n.d.). Patient Safety in Emergency Medical Services Advancing and Aligning the Culture of Patient Safety in EMS. Retrieved from https://www.patientsafetyinstitute.ca/en/toolsresources/research/commissionedresearch/patientsafetyinems/documents/patient%20safety%20in%20ems%20full%20report.pdf
• Canadian Centre for Occupational Health and Safety. (2023). Ergonomic safe patient handling program. Retrieved from https://www.ccohs.ca/oshanswers/hsprograms/patient_handling.html
• Canadian Medical Protective Association. (2021). Resolving conflict between healthcare providers. Retrieved from https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2021/resolving-conflict-between-healthcare-providers
• Canadian Nurses Protective Society. (2021). InfoLAW: Delegation to other health care workers. Retrieved from https://cnps.ca/article/delegation-to-other-health-care-workers/
• Canadian Patient Safety Institute. (2020). The Safety Competencies: Enhancing Patient Safety Across the Health Professions. 2nd Edition. Edmonton, AL.
• Clarke, S., & Donaldson, N. (2008). Chapter 25: Nurse staffing and patient care quality and safety. In R. Hughes, Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality.
• College of Nurses of Ontario. (2013). Practice guideline: Working with unregulated care providers. Toronto, ON.
• College of Registered Nurses of Manitoba. (2023). Assignment and delegation to unregulated care providers. 
• CSA Group. (2018). Z1003.1-18 Psychological health and safety in the paramedica service organization. Toronto ON: CSA Group. Retrieved from https://www.apbc.ca/wp-content/uploads/2022/09/CSA-Z1003.18-Paramedic-Psych.pdf
• Edwards, K., FitzGerald, G., Franklin, R., & Edwards, M. (2020). ir ambulance outcome measures using Institutes of Medicine and Donabedian quality frameworks: protocol for a systematic scoping review. Syst Rev, 9(72). doi:doi.org/10.1186/s13643-020-01316-
• Feil, M., & Gardner, L. A. (2012). Pennsylvania Patient Safety Advisory, 9(3), pp. 73-81.
• Health Quality Council of Alberta. (n.d.). New Study: EMS Key Performance Indicators. Retrieved from https://hqca.ca/feature-story/new-study-ems-key-performance-indicators/
• Health Research & Educational Trust. (2018). Falls with injury change package: 2018 update. Chicago, IL.
• Incident Analysis Collaborating Parties. (2012). Canadian Incident Analysis Framework. Edmonton, AB.
• Jessamyn, P., Malliaris, A., & Bakerjian, D. (2021). Nursing and patient safety. PSNet primers.
• Machen, S. (2023, 5). Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report. BMJ Open Quality, 12(2), e002020.
• Massachusetts General Hospital Centre for Disaster Medicine. (2018, 7). Hospital Preparedness for Unplanned Information Technology Downtime Event. Retrieved from Massachusetts General Hospital: https://www.massgeneral.org/assets/mgh/pdf/emergency-medicine/downtime-toolkit.pdf
• Ministry of Health Ministry of Long-Term Care. (n.d.). Land Ambulance Key Performance Indicators. Retrieved from https://www.health.gov.on.ca/en/pro/programs/emergency_health/land/default.aspx
• Ministry of Health Ministry of Long-Term Care. (n.d.). Emergency Health Services Ambulance Call Report (ACR) Codes. Retrieved from Ministry of Health Ministry of Long-Term Care: https://www.health.gov.on.ca/en/pro/programs/emergency_health/edu/acr_codes.aspx#1
• Ministry of Labour, Immigration, Training and Skills Development. (2022). Client handling in health care. Retrieved from https://www.ontario.ca/page/client-handling-health-care
• National EMS Quality Alliance. (2021). NEMSQA Measures. Retrieved from National EMS Quality Alliance: https://www.nemsqa.org/measures
• Noack, E., Kleinert, E., & Muller, F. (2020). Overcoming language barriers in paramedic care: a study protocol of the interventional trial ‘DICTUM rescue’ evaluating an app designed to improve communication between paramedics and foreign-language patients. BMC Health Services Research, 20(223). doi:doi.org/10.1186/s12913-020-05098-5
• Ontario Association of Non-Profit Homes and Services for Seniors. (2011). Fall prevention and management program policy, procedures and training package. 
• Ontario Health. (2022). Client handling in health care. Retrieved from https://www.ontario.ca/page/client-handling-health-care#:%7E:text=Related-,Overview,due%20to%20repetitive%20client%20handling
• Registered Nurses’ Association of Ontario. (2017). Preventing Falls and Reducing Injury from Falls (4th ed.). Toronto, ON: Author.
• Sadaka, N. (2022). Language Barriers in an Out-of-Hospital Setting. Journal of Emergency Medical Services. Retrieved from https://www.jems.com/patient-care/language-barriers-in-an-out-of-hospital-setting/