Patient Falls

Service: Risk Management
Subject: Care
Setting: Falls

A fall is defined as an inadvertent event which results in a person coming to rest on the ground or floor or other lower level (World Health Organization, 2018). Injuries caused by falls frequently result in significant disabilities with loss of independence and associated costs. Safety is fostered by both fall prevention and by reducing the severity of injury should a fall occur. Multifaceted strategies may be utilized including: screening for fall risk factors, fall risk assessment, implementation and assessment of targeted prevention strategies, communication of identified risks, education about and evaluation of adherence to fall prevention practices.

Common Claim Themes

System

  • Lack of an organizational or agency falls prevention program.
  • Inadequate availability 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, and uneven surfaces). 
  • Inadequate documentation of preventative maintenance on patient equipment.
  • Inability to access care plan (home care).

Knowledge and Judgement

  • Inconsistently completed falls risk assessment and/or reassessment where indicated. 
  • Inconsistently and/or inadequately performed injury assessment after a fall. 
  • Lack of awareness of the organizational or agency safety patient handling and mobility practices.
  • Falls involving care providers not sufficiently trained in safe lifting and transferring of patients.

Communication and Documentation

  • Inadequate communication and documentation of risk assessments and care plans.  
  • Failure to communicate patient’s falls risk status (e.g., falls history, sedation prior to a diagnostic test) during patient handoffs or transfers of care. 
  • Lack of awareness of degree of falls risk due to the absence of falls risk cues (e.g. ,arm band, patient room signage, health records flag).
  • Inconsistent reporting of fall incidents.

Case Study 1

An elderly diabetic resident at a chronic care facility experienced several minor falls with no injury over the period of one week. The resident was moved to the room closest to the nursing station and placed on observation (i.e., q15 minutes). The resident experienced several more falls including one that caused a hip fracture requiring surgery and rehabilitation. Expert review of the team’s care was not supportive. Of particular concern was the team’s failure to perform ongoing falls assessments as clinically indicated in addition to their inconsistent documentation of their close and routine observations of the patient. Experts also noted that the resident had reported the broken bed rail (which contributed to the fall) to the team but remedial action had not been taken. 

Case Study 2

A rehabilitation facility client with paralysis and spasticity suffered a head injury after a fall during a routine bed-changing procedure. As a result of the head injury, the client developed a blood clot on the brain which required emergency surgery. Expert review of the case was critical of the transfer technique employed by the team members, as they failed to ensure that necessary adjustments were made to account for the risk of abnormal posturing. Furthermore, the experts felt the team failed to reassess the patient during the transfer. It was noted that no person or side rail had been positioned to ensure that the heaviest sections of the client’s body were prevented from moving off of the bed when the bed linens were being adjusted. Experts were also critical of the organizational delay in notifying the client’s family of the incident.

Mitigation strategies

Reliable Care Processes

  • Implement an evidence-based enterprise-wide fall prevention program, that includes (but is not limited to):
    • Standardized definition of a patient fall;
    • Adoption of ‘universal falls precautions’ (e.g., promoting safe mobility, call button in reach, adequate and appropriate flooring, lighting);
    • Standardized, evidence-based and validated falls risk screening and assessment tool;
    • Triggers or criteria for conducting a falls screening and assessment (e.g., on admission, significant change in health status or transitions);
    • Patient falls risk cues (e.g.,  patient arm band, patient room signage, and/or health record flag);
    • Conducting medication reviews for polypharmacy and/or those groups associated with side effects which have the potential to increase the risk of falls (e.g., opioids, psychotropics, cardiac medications, hypoglycemic agents);
    • Standardized mobility and handling criteria and/or algorithms (e.g., one or two-person manual lifts).
  • Implement evidence-based interdisciplinary integrated care pathways and/or standardized algorithm(s) for falls prevention and management; support and expect individually tailored multifactorial interventions and care plans as required.
  • Adopt standardized communication practices including documentation of the communication of falls risk status and patient-specific falls prevention plan at handoffs, huddles, and with patient and family members.
  • Implement regular rounding for proactive assessment of:
    • Environmental falls hazards (including in the home health settings);
    • Patients’ fall prevention needs.

Education

  • Offer interdisciplinary team-based educational sessions and in-situ simulation training related to patient fall prevention and management, including (but not limited to):
    • Safe patient handling and mobility training;
    • Management of patients with aggressive behaviors or cognitive impairments.

Equipment and Technology

  • Implement formal strategies to ensure:
    • A sufficient number and type of functioning falls prevention and detection technologies based on patient acuity and volumes;
    • Equipment such as call bells and bed rails are in proper working order (e.g., scheduled preventative maintenance program);
    • Patient mobility aids and frequently-required personal possessions are kept at the bedside and/or within reach, and is kept clutter free. 

Responding to Patient Falls

  • Adopt a standardized process, checklist and/or algorithm to aid decision-making following a patient fall, including (but not limited to):
    • Offer safety and support, but do not move the patient 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 family (with consent or as appropriate);
    • Monitor and reassess the patient (e.g., frequent neurological and vital signs);
    • Documentation (all observations, patient/family statements, assessments, notifications, interventions, evaluations, etc.);
    • Conducting a post-fall debrief to identify modifiable fall risk factors and make changes to the patient’s care plan as required. 

Monitoring and Measuring

  • Implement formal strategies to monitor and measure the effectiveness and efficiency of, and adherence to fall prevention and management guidelines, protocols and algorithms, including:
    • Adoption of formal quality measures and indicators; 
    • Sharing learnings from near miss and harm incidents involving patient falls (e.g., chart audits, trigger tools, incident reports, team debriefs, critical incident and quality of care committee reviews, medical legal claims, coroner reports and related recommendations).

References

  • HIROC claims files
  • Hawkins P. (2018). Lessons learned from recent cases: The importance of documenting maintenance activities. Borden Ladner Gervais.
  • Boushon B, Nielsen G, Quigley P, et.al. (2012). Transforming care at the bedside how-to guide: Reducing patient injuries from falls. Institute for Healthcare Improvement.
  • Bursiek A, Hopkins M, Breitkopf D, et.al. (2017). Use of high-fidelity simulation to enhance interdisciplinary collaboration and reduce patient falls. J Patient Saf. 16(3):245-250
  • Feil M, Gardner L. (2012). Falls risk assessment: A foundational element of falls prevention programs. Patient Saf Advis. 9(3):73-82.
  • Ganz D, Huang C, Saliba D, et.al. (2013). Preventing falls in hospitals: A toolkit for improving quality of care. Agency for Healthcare Research and Quality.
  • Goldberg T, Byrick K. (2009). The use of restraints: Recommendations from a recent inquest. The HIROC Connection, (20):1-2.
  • Health Research and Educational Trust. (2018). Falls with injury change package: 2018 update. 
  • Health Standards Organization. (2018). Fall prevention and injury reduction: Inpatient services. Global Standard.
  • Institute for Safe Medication Practices Canada (ISMP Canada). (2015). Medication incidents that increase the risk of falls: a multi-incident analysis. ISMP Canada Safety Bulletin, 15(12):1-5.
  • Local Health Integration Network Collaborative. (2011). Integrated provincial falls prevention framework & toolkit.
  • Long-Term Care Homes Act, Statutes of Ontario. (2007, C-8).
  • Ontario Association of Non-Profit Homes & Services for Seniors. (2011). Fall prevention and management program: Policy, procedures and training package. 
  • Registered Nurses’ Association of Ontario. (2017). Preventing falls and reducing injury from falls. Clinical Best Practice Guidelines.
  • Registered Nurses’ Association of Ontario. (2017). Evidence booster: Perley and Rideau Veterans' Health Centre: Impact of best practices on fall rates. Implementation Resources.
  • Safer Healthcare Now! (2015). Reducing falls and injuries from falls: Getting started kit.
  • Scott V, Bornstein S, Kean R, et.al. (2014). Fall prevention for seniors in institutional healthcare settings in Newfoundland & Labrador. Newfoundland & Labrador Centre for Applied Health Research. 
  • World Health Organization. (2018). Falls. Fact Sheets.