SDS Accreditation Update

Don't wait for a patient fall in your facility: Evaluate your program now to address issues

NPSGs, standards require risk assessment, prevention

San Leandro (CA) Surgery Center typically experienced one or two patient falls a year, so managers were shocked when three falls occurred in a three-month period in early 2006. Those falls led to development of a prevention program that has been honored with an Innovations in Quality Award from the Accreditation Association for Ambulatory Health Care.

The center has tracked patient falls in its quality improvement data since 2001, but with so few falls, there was no indication that there was an increasing risk, says Jeanne Linda, RHIT, CPMSM, CPHQ, director of medical staff services and quality review for the center. Following the series of three falls, the staff performed a root-cause analysis of each incident, she says. One of the causes identified was a number of new staff members who had less experience with patient transfers, Linda says. "We identified the need for more education for all staff members related to patient transfers, more patient education, and more active communication between staff members."

It was important that active communication be emphasized because nurses are accustomed to handling things by themselves, and they often are reluctant to call out for help, says Sheila L. Cook, executive director of the center. Although everyone is busy, every staff member should be comfortable calling out, "I'm having trouble here," she says. "In our follow-up educational programs, we gave everyone permission to ask for help because it not only protects the patients if the nurse is having trouble with the transfer, but it also protects the nurse from injury as he or she tries to catch a falling patient."

In addition to encouraging staff members to ask for help, an ergonomics expert was brought to the center to conduct an inservice on the proper techniques for transferring patients, says Linda. "It was a 2½-hour educational and hands-on workshop in which we practiced transferring patients in different situations," she says. Staff members learned how to transfer patients between chairs and gurneys as well as from wheelchairs to cars, she says.

Staff members also learned how to use tools such as transfer boards and transfer belts, says Linda. "We weren't using any tools to help with patient transfers before we evaluated the program," she says. "Now, the staff is confident that transfers are safer for themselves and for patients because there is more support for the patient."

Assess patient risk for falls early

There are several reasons to focus on patient falls as both a quality improvement program and a patient safety issue, says Linda.

"Not only do accreditation standards require that we ensure patient safety, but it is important to involve the staff in identifying and solving problems," she says.

The experience at the San Leandro center is not isolated, says Susan R. Chmieleski, APRN, FASHRM, JD, vice president of risk management and client services for Farmington, CT-based Darwin Professional Underwriters. "Our company has only been writing malpractice insurance for ambulatory surgery centers for three years, but during that time we have seen claims related to patient falls increase," she says.

An increase in falls in an outpatient surgery setting is not surprising when you consider that as more procedures and as older patients are moved into outpatient surgery, the staff are seeing patients with more medical problems and at higher risk for falling, Chmieleski says. "Some procedures that are now only performed as outpatient procedures, such as cataract surgery and colonoscopy, are routinely performed on elderly patients who have balance problems or a history of falls," she says. "Add anesthesia and a lack of food for a period of time before surgery, and you increase the chance for dizziness and falls." For these reasons, every outpatient surgery program should have a risk assessment for falls built into their pre-surgical assessment form, she recommends. Patients who are at higher risk for falls can be identified by age, medications, visual impairment, or medical conditions such as diabetes or obesity, says Chmieleski. While you should ask all patients about their history of falls or problems with balance and you should be aware of all medications that might affect balance, be especially alert to patients who are in the higher risk category, she suggests.

Don't forget to look at the type of surgery and anesthesia that the patient will undergo, says Cook. "Age is not as much of a factor in assessing falls risk as the type of anesthesia," she explains. "We've seen an increase in the use of blocks, and a 28-year-old undergoing an orthopedic procedure who doesn't have full control of his legs will fall just as easily as a 70-year-old."

Once the risk for falling is determined, be sure that the patient is not left alone, Chmieleski says. "Most falls occur when a staff person is not immediately present and the patient attempts to go to the toilet or move off the bed," she says. Although many outpatient surgery programs allow family members to be with the patient during the final stage of recovery, be sure that the family members understand the risk of falls, Chmieleski says. "Everyone forgets that outpatient surgery is serious, and family members see the patient talking and feeling fine. They forget that anesthesia can affect balance," she says.

Staff members not only should educate the patient and instruct them not to move around without a staff person present, but they also should inform family members of the risk of falls, says Chmieleski.

Another key part of education for orthopedic patients is instruction on how to use crutches, points out Chmieleski. "This is probably the first time the patient has used crutches, so teach the patient before surgery and before any medication is administered," she suggests. Let them walk with crutches on carpet as well as a smooth surface such as a linoleum floor, she says.

A surgery program's responsibility doesn't end at the front door of the center, so make sure that the sidewalk is in good repair and that it is easy to get from a wheelchair to the car, says Chmieleski. "Be sure, too, that family members are prepared to help the patient from the car into the house and that they understand how long the effects of anesthesia might affect the patient," she says. "Just because you are not legally responsible for a fall that occurs in the home, ethically, you should make sure the patient and family understand the risks."


For information about ergonomics training, contact:

  • Onsite Ergonomics Inc., P.O. Box 3938, Walnut Creek, CA 94598. Telephone: (925) 673-3009. Fax: (925) 476-1566. The company provides worksite ergonomics training to a variety of industries, including health care. Price is determined by needs, number of employees, and number and type of educational sessions.