Engineers study design, hospital cuts falls 50%

Outside engineers can give risk managers a fresh perspective on design and procedures that affect the likelihood of patients falling, according to a team that was able to reduce falls in one hospital by more than 50% in fewer than two years.

After accumulating a higher-than-average number of patient falls in recent years, Our Lady of Lourdes Hospital in Pasco, WA, called in engineers from Pacific Northwest National Laboratory (PNNL), a division of Battelle, an engineering and consulting firm in Columbus, OH. The hospital's risk management staff asked the engineers to help in meeting new patient safety standards set by the Joint Commission on Accreditation of Healthcare Organizations, notes PNNL's Jonathan Young, a senior scientist who worked with the risk assessment team. The Joint Commission standards call for using failure mode analysis to analyze one high-risk process each year, Young says. Anita Kongslie, director of quality management at Lourdes, says she immediately knew that patient falls were the first topic to address.

Kongslie notes that the hospital's fall rate was excessive in part because it has a physical medicine rehab unit as well as an acute care hospital. That unit means there is a lot of therapy involving patients who are trying to regain the skills of daily living, in addition to the falls typical of any patient population. In addition, Kongslie noticed that rehab patients were having a lot of falls toward the end of their stay, as the staff encouraged them to become more independent.

"We believed our fall rate was a little high, but we weren't sure how to do failure mode analysis," she says. "That's why we called in outside engineers with experience in this method."

At the time, patient falls led to the highest payouts at Lourdes, Kongslie says. Now it has been about three years since the hospital had a fall that led to a significant payout. "It's totally dropped off the radar screen at this point, in terms of being a major expense for us," she says.

New eyes see new things

The impressive results were brought about by having someone other than the risk management staff take a fresh look at the problem, Kongslie says.

"They see things that we have looked at for so many years that it just goes right by us. It doesn't register to us as a problem," she says. "But they come in with a fresh pair of eyes and say, 'Hey, what about that? Isn't that a problem?' And then we have to stop and say, 'Yes, that could really be something.'"

Young mentored Lourdes staff in the use of failure mode analysis, a common engineering tool in risk assessment, to examine the policy, procedures, and practices related to patient fall risk. The basic concept of the analysis is to identify the elements of the process, the failure modes of that process, and the effects of that failure on the organization. Then the analysis moves on to trying to estimate the relative likelihood and severity of the consequences of each of the failure modes. Then that information is used to identify the most significant failure modes and how to address them.

The engineers also identified the safeguards in the current process, such as double-checking patient charts to make sure patients at risk of falling were properly identified when they were first admitted to the hospital. An algorithm was used to score the vulnerability in the system, and it categorized those failure modes as high, medium, or low risk.

Detailed data collection helped Kongslie and the PNNL engineers spot trends and possible problems with the physical surroundings. In addition, Lourdes now implements an updated patient assessment of fall risk upon the patient's arrival at the hospital, holds staff refresher courses, uses bed alarm systems, color-codes charts of patients at risk of falling, and improved the Patient Fall Risk Care Plan process to allow hospital staff to provide the proper level of patient care.

Must work actively with consultants

Fall prevention also is a bigger focus now in new staff orientation, Kongslie says. The hospital was going restraint-free at the same time, so that change brought an added challenge for fall reduction. One solution was to use more sitters for patients at high risk of falling, instead of restraints. The physical medicine rehab unit is now entirely restraint-free.

"We've done all the things that most facilities have done, like bed alarms, but the key for us was looking for trends in location of falls and taking an all-inclusive approach to fall assessment," she says. "We also revised our fall assessment to include the type of medications that patients are on and increased our education to staff."

Young notes that Lourdes was so successful in reducing falls partly because the risk management team was directly involved in the analysis and problem solving. While it can be useful to bring in outsiders to give you a fresh look, he says, the most success comes when risk managers work alongside those investigators.

"You get much better results that way than if you just wait for them to drop a report down on your desk," he suggests.


For more information on reducing patient falls, contact:

  • Anita Kongslie, Director of Quality Management, Our Lady of Lourdes, 520 N. Fourth, Pasco, WA 99302. Telephone: (509) 546-2273. E-mail:
  • John Young, Battelle, 505 King Ave., Columbus, OH 43201-2693. Telephone: (614) 424-6424. E-mail: