Be sure procedures are in place to prevent falls

It was a provider's worst nightmare. An 86-year-old woman had just undergone surgery in Boston to replace a broken hip. As the staff prepared to transfer her to a bed, a nurse removed a safety strap, according to a media report.1 She then walked toward the patient's left side so a bed could be placed on the right side for the transfer.

The orthopedics surgical table features boots to immobilize patients' feet and a large opening near the base of their torso to facilitate X-rays.

As the nurse started to walk, "she looked at the patient and saw (with horror) that she was falling from the table, buttocks first, through the opening between the torso and the lower leg table sections," according to an investigative report by the state Department of Public Health.

The nurse lunged toward the patient, but the patient fell through the table, struck her head on the floor, and suffered a massive head injury. She died within a few days.

The hospital's root-cause analysis determined that the providers were preoccupied with their tasks and that the "removal of the ... safety belt from the patient was not verbally communicated." Since that time, the hospital has adopted a protocol that requires all nurses and doctors to put their hands on the patient before removing the safety belt and to ensure that there are people on both sides of the table. The family has filed a lawsuit.

Ambulatory surgery patients may be particularly susceptible to falls, surgery experts warn.

Previously, outpatient surgery providers took care of a basically healthy patient population, says Bonnie G. Denholm, RN, MS, CNOR, perioperative nursing specialist at the Center for Nursing Practice, Association of periOperative Registered Nurses. "I think that's changing now," she says. "The acuity is more. The population is getting older." Older patients may have osteoporosis, she points out. "The bottom line is that there needs to be awareness [of falls] in ambulatory centers," she says. "When a patient is anesthetized, you have the same risks for falling in an ASC as you have in any other operating room setting, and the same precautions and basic safety principles should apply."

8 tips to protect patients from falling

Consider the following steps to protect patients who may be susceptible to falls:

  • Confine medicated patients to a stretcher.
  • Use bumper pads for children.
  • Don't remove the safety strap until the time to move the patient to the stretcher. Make sure someone is on both sides of the patient. If you undo the safety strap to reposition the patient, don't walk away.
  • Make sure someone is in attendance with a medicated patient.
  • Consider moving patients, especially elderly ones who may have vision problems, to the OR on a stretcher, even if they're not overly medicated.

The Association of periOperative Registered Nurses (AORN) offers these additional tips in its recommended practices:

  • Locking wheels, raising side rails, and securing safety straps will help to reduce the risk of patient falls when transporting patients and preparing them for transfer and positioning on procedure beds.
  • Perioperative registered nursing assessment of the patient's risk for falling and continuous surveillance are keys that should be incorporated into the health care organization's fall-reduction program.
  • If the following items appear in the nursing preoperative assessment, the patient should be considered to be at a high risk for falling: recent history of a fall, mobility problems, dizziness, poor vision, postural hypotension, and altered mental status. (Editor's note: AORN's newly updated "Recom-mended Practices for Positioning the Patient in the Perioperative Practice Setting" is published in the Perioperative Standards and Recommended Practices, 2008 Edition. To purchase the book, visit

Outpatient surgery programs in both hospitals and freestanding centers emphasize the quick ambulation of patients after surgery, says Kate Moses, RN, CNOR, CPHQ, quality management nurse at the Medical Arts Surgery Center (MASC) in Miami. "Sometimes they've just had sedation, so they're more active, quicker, in post-op," she says. "In the recovery area, you need to make sure they won't slip and fall."

Get ready to report falls

Ambulatory surgery centers may be required in the future to report falls as a quality measure. The ASC Quality Collaboration Group is determining the measures for which surgery centers will be responsible. (Editor's note: For more information, go to

The ASC group is working with the National Quality Forum, which endorsed five measures in November 2007, including the number of patients who experience a fall within the surgery center.

"I know that's one of the measures we're going to be held accountable for," Moses says.

Another reason to be concerned about patient falls is the trend toward adopting policies to not bill patients or insurers when "never events" occur, including includes patient death or serious disability associated with a fall while being cared for in a health care facility.

Beginning Oct. 1, 2008, the Centers for Medicare & Medicaid Services (CMS) won't pay hospitals for cases that include a patient fall or for any repair work, Denholm says. Surgery center managers should prepare for such a policy to be implemented for them in the future, she says.

Also, The Joint Commission has patient falls on its radar. As of Dec. 31, 2007, there had been 281 patient falls reported to The Joint Commission. Falls were the sixth most common sentinel event; 5.8% of all sentinel events were falls. There already is a National Patient Safety Goal for hospitals, and they are required to implement a fall reduction program and evaluate the program.

Every facility and patient is at risk

To avoid patient falls, realize that everyone is at risk, Denholm says. While providers often think of the elderly as the most vulnerable, children are also at risk, she says. "They crawl around coming out of anesthesia," she says.

Children can be very active, Moses says. "They should be either with their parents or in a situation where they shouldn't have the opportunity to fall," such as cribs, she says. If the child is not with the parents or restricted, a nurse should stay with the child, Moses says.

Denholm points out that freestanding staff may have to handle the same areas that increase fall risk at hospitals, such as ice on sidewalks and wet floors, but in a hospital there often are staff designated to address such potential problems. "In an ASC, you're the whole gamut," she says.

Also keep in mind that visitors, as well as patients, can fall, Denholm says.

For patients, the key is a thorough preoperative assessment, sources say.

"Document that they're dizzy, their eyesight is not good, they have a history of falling, they have osteoporosis, so you have a nice flag for others that this patient is a higher risk for falls than others," Denholm says.


1. Saltzman J. Family sues in operating room fall — Matriarch suffered a fatal head injury. The Boston Globe. Jan. 29, 2008. Accessed at fall. Source/Resource

For more information about preventing patient falls, contact:

  • Kate Moses, RN, CNOR, CPHQ, Quality Management Nurse, Medical Arts Surgery Center (MASC), 8940 N. Kendall Drive, No. 201E, Miami, FL 33176. Telephone: (786) 596-7556. E-mail:

As part of its Learning Management System, Joint Commission Resources offers an online educational program titled It's a Long Way Down: Reducing the Risk of Patient Falls. The course costs $275 and includes CE contact hours. Go to Click on "Audioconferences and Distance Learning" and then "Online Education," Under "JCR Online Education — Complete List-ing," click on the title. For more information, call (630) 268-7400.