Respond quickly and thoroughly
You’re busy with a dozen other issues when you get a phone call notifying you that a visitor has fallen in the lobby and broken her arm. Do you chalk it up to "just another fall" and get back to work, or do you spring into action? The answer may depend on how well you’ve prepared for the moment and how seriously you take slips and falls in your institution. The experts say that if you’re taking the right steps to reduce falls and all the attending liability, you’ll probably get up from your desk and make investigating the incident a top priority.
A speedy response and full-scale investigation may not be necessary for every incident. But the more serious the fall, the more you should pull out all the stops in your response. A serious injury such as a broken arm is enough to justify a full response, says Ronald Miller, CSP, director of training and consulting services for the occupational safety and health group of the National Safety Council in Itasca, IL.
"Most employers handle this rather poorly," he says. "Most of the companies I’ve worked with needed extensive training on how to do a good investigation. If a health care provider wants to reduce falls, you need to take a hard look at what happens when someone falls."
There could be a tough decision to make in some circumstances, though, with the primary question being: If you document the incident well enough to learn from it, will you create ammunition for a plaintiff’s attorney?
Many willfully avoid documenting the incidents for fear of creating evidence that can be used against them in court, says Russell J. Kendzior, CSP, president of the nonprofit National Floor Safety Institute (NFSI) and Traction Plus, a manufacturer of slip-and-fall prevention products, both in Southlake, TX. He often testifies as an expert witness for slip-and-fall cases, and says health care staff often are conspicuously unable to show documentation of the incidents.
The problem is bad, especially in nursing homes, where the risk and potential liability from falls are the greatest, he says. "One unfortunate reality in health care is that they often have been trained by risk managers, loss-control experts, and third-party claims managers to be very vague in gathering information," he says. "They will say you don’t want to collect or track certain information because it can only come back to haunt you in court. I know that sounds crazy, but I see it a lot."
Some health care providers even choose not to have a policy on the prevention of slips and falls, for fear that a plaintiff’s attorney will use it to prove that the facility was not following its own policy. Kendzior says that is a very poor strategy if you’re trying to reduce falls, which he calls "by far the biggest risk your patients face while they’re in your care."
Responding properly to a fall is important, but Kendzior says a proactive program is even more effective. The risk manager should work closely with the engineering and housekeeping departments to ensure that floors are maintained in such as way as to minimize the risk of falls, he says.
Every fall, and most near misses, should be investigated thoroughly, Miller says. Sometimes, the local supervisor can be trusted to conduct the investigation and document the incident, but sometimes, the seriousness of the fall requires a multidisciplinary team approach. That team may include the risk manager, director of safety, the facility’s head engineer, the director of housekeeping, and the manager of the unit where the incident happened.
Employees, especially managers, should be educated about the need to preserve evidence and investigate after falls. "Incident investigations should be done immediately because conditions change," he says. "If there is a hazard on the floor like a spilled liquid or bodily fluid, someone is going to clean it up quickly, especially after there is an incident. Unless the investigation is done quickly, you may never find that root cause. The cause could be a motorized equipment cart with an oil leak, and if the spill has been cleaned up and no one remembers leakage from that cart, you may never find it."
When you investigate a fall, Miller says you should gather as much information as possible about the area and the activity leading to the fall. Document the information and consider photographing pertinent scenes, especially those that may mitigate the institution’s liability for the fall. Investigators often photograph the area in which the person fell and maybe even the fluid spill that caused it, but they sometimes overlook documenting the precautions that mitigate the damages. For instance, you may wish to photograph the "wet floor" sign that housekeeping had in place to warn people, or the handrails that helped the person avoid a more serious fall.
The incident investigation after a serious fall should follow the same methodology and strive for the same goals as a root-cause analysis after an adverse medical event, Miller says. The goal should be to uncover the real cause of the fall, not just the defect that appears most obvious.
Just as with less-than-optimal investigations of medical incidents, a common failing of fall analyses is blaming the employee who fell or who made the fall possible by leaving a hazard on the floor, he says. That rarely is the root cause.
"Most reports by a supervisor will conclude that the way to fix the problem is to retrain the employee, but you’ll never see one that says, Retrain the supervisor,’" Miller says. "If you don’t focus on the root-cause analysis, you’ll stop before you find the real problem."
Punishing employees or laying all the blame on them also will discourage the free reporting that is so important for good fall investigations, he says. If your employees only report the ones they have to report — the falls that leave someone lying on the floor needing medical help — you’ll miss the opportunity to learn.
When investigating and analyzing the data, Miller says you should focus on these four areas that lead to most slips and falls:
• Equipment: Check to see if any items were defective, such as handrails that did not support the person or anything that could have led to tripping.
• Environment: This area includes all types of hazardous conditions, such as the condition of stairs and floors. Was there blood or other fluid on the floor? Why? How long had it been there?
• Management: Ascertain whether there was a breakdown in management, such as allowing employees to run through the department. Was management condoning it or even encouraging it?
• People: Who fell? Was the person impaired in any way? What was he or she doing at the time of the fall? Also consider the type and condition of the person’s shoes.
Miller says most falls can be traced to failures in at least three of those categories. "And remember that you have to do something with the data," he says. "If you don’t use it to improve, you’re just wasting your time and opening yourself up for more incidents."