Prevention of falls and fires may make their way to the top of new safety goals

Start now to assess your risk, improve prevention efforts

Several perennial worries of risk managers are under consideration by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as new National Patient Safety Goals for 2005, and experts in two of the hottest topics say you should assess your efforts in these areas now. Both topics — harm from patient falls and the risk of surgical fires — need your attention even if they don’t become National Patient Safety Goals, experts say.

The fact that JCAHO is considering them as new National Patient Safety Goals is evidence of the threat they pose, says Mark E. Bruley, vice president for accident and forensic investigation with ECRI, a nonprofit health and safety research organization in Plymouth Meeting, PA. He worked with JCAHO to compose advice regarding surgical fires in 2003 and has worked extensively with state agencies on the topic. If JCAHO adopts them as National Patient Safety Goals, the bar is raised considerably higher because failure to address them could result in sanctions from the accrediting body. Start now, and you’ll be in better shape if JCAHO says you must address these hazards, Bruley says.

JCAHO spokesman Mark Forsteneger confirms that risk from patient falls and surgical fires are both being considered as National Patient Safety Goals for 2005, and JCAHO is considering comments from health care providers.

Bruley says surgical fires were considered last year as a National Patient Safety Goal, but other topics took precedence. He tells Healthcare Risk Management that he hopes surgical fires will become a National Patient Safety Goal for 2005. "At ECRI, we get at least one report and sometimes four every week," he says. "We estimate that there are at least 100 surgical fires a year, and of those, about 20% are serious and one or two are fatal. This is a true risk, not something theoretical."

Bruley suspects the risk of surgical fires actually is greater than that of wrong-site surgery, which has received so much attention lately. The number of reported fires appears to be on the increase now that JCAHO and others are addressing the risk more prominently, he notes.

However, Bruley warns that a key recommendation for preventing surgical fires is not receiving enough attention. The recommendation is that clinicians question the need for 100% oxygen delivered to the patient’s face through a nasal cannula or mask. "That is something that a risk manager could encourage," he says. "Urge the anesthesiology department and other clinicians to seriously consider some practices they might take for granted."

Many fire prevention efforts in hospitals overlook the problems posed by interdepartmental friction, Bruley says. This is where risk managers can play a key role, he suggests. In developing processes to reduce the risk of fire, and especially after a fire has occurred, there can be tremendous conflicts between surgery, anesthesiology, and nursing.

"Surgical fires are very much a cross-cultural hazard. The best analogy is with wrong-site surgery, with the way everyone now recognizes that every single person on the team is responsible for preventing wrong-site surgery," he says. "The risk manager can act as a coordinator between those departments so that they see their roles and how they can work together, and not try to say someone else is responsible."

Like wrong-site surgery, Bruley says, virtually all surgical fires are preventable.

Fires already a major focus

JCAHO already has made surgical fires a focus point with its Sentinel Event Alert on June 24, 2003. (To access the Alert, go to and search for Sentinel Event Alert issue No. 29.) In that Alert, JCAHO reiterated advice that ECRI also has offered for more than 20 years, Bruley says. First, administration and risk managers should be proactive in preventing surgical fires. Second, the surgical team needs to understand heat sources and manage fuels, especially alcohol-based prepping agents. And third, the team should minimize oxygen buildup under drapes.

"If it becomes a Patient Safety Goal, the hospital as a whole is going to be assessed for how well it is addressing this hazard, so the risk manager can make a good case for having policies and procedures, along with a good education program," he says. "Risk managers have a vital role to play in all of this."

Aside from protecting patients, the risk manager should be concerned with the potential liability of not preventing a surgical fire, Bruley says. His experience with surgical fires suggests that they lead to costly lawsuits.

"They can certainly go into the millions of dollars. I’ve seen that," he says. "If it’s a teaching facility where all the physicians, anesthesiologists, and nurses are insured by that facility, then the entire liability may fall on the institution. If there is segregated insurance between surgery, anesthesia, and OR [operating room] nurses, then that’s where the interdepartmental difficulties can come in with lots of finger pointing and blame."

Bruley notes that risk managers will have to address both clinical issues, such as whether 100% oxygen is really necessary for a patient, and also procedure issues such as what team member is responsible for placing electrosurgery tools on standby when not in use so they cannot be accidentally fired.

"Risk managers must encourage discussion of the clinical decisions, even if the decision still has to be made by physicians," he says. "Develop a culture that encourages discussion and makes it OK to talk about it. The proposed goals will make it necessary to talk about it, so you’re better off if you start now with creating that culture."

(For more on surgical fires, see box, below. For a surgical fire safety poster you may reproduce, click here.)

Most surgical fires involve electrosurgical gear, oxygen

These facts about surgical fires are provided by ECRI, a nonprofit health and safety research organization in Plymouth Meeting, PA:

• About 68% of surgical fires involve electrosurgical equipment as the ignition source, and another 13% involved lasers. Other potential sources of ignition include electrocautery tools, fiberoptic light sources, defibrillators, and high-speed burs.

• About 34% of reported fires occur in the airway. Twenty-eight percent occur on the face and another 24% elsewhere on the patient. The remaining 14% occur elsewhere in the patient.

• Oxygen-enriched atmospheres are present in 74% of surgical fires.

 Focus on reducing harm from falls

Concerning patient falls, JCAHO is focusing specifically on reducing harm from falls rather than simply reducing falls, says Marianna Grachek, CNHA, MSN, RN, JCAHO’s executive director for long-term care and assisted-living accreditation. She also is executive director of health care staffing certification. "We know that falls are going to happen in the care setting, but we need to look at how we can reduce the harm from those falls," Grachek says. "This National Patient Safety Goal involves early detection, a risk assessment, and identifying the appropriate strategies to reduce falls and injuries from falls."

Grachek’s background is in gerontological nursing, so she is familiar with reducing falls and patient harm in long term care settings but notes that the National Patient Safety Goal, if accepted by JCAHO, would apply across all health care settings. The distinction between reducing falls and reducing harm from falls may be familiar to those in a long-term care setting but might seem like a new perspective to others, she says.

"The population you’re working with will determine how you apply this goal in your organization," Grachek says. "If you have many elderly residents, the things you do to reduce harm from falls will be different from what you do if you have mostly children. There will be nuances in how you pursue this goal."

Reassess previous strategies

Reducing the risk of harm from falls starts with assessing the patient, Grachek says. Assessing their physical functioning, cognitive abilities, gait, and endurance, for instance, will help you identify those patients most at risk and guide your prevention efforts. Of course, risk managers have worked to reduce falls for many years, so the basic idea is nothing new. But Grachek says changes in health care necessitate looking at the problem with a fresh perspective.

The dramatic reduction in the use of restraints over the past few years, for instance, has changed the way providers must address the risk of falls. "Even side rails are not being used as much anymore. When I first started out in nursing, if you were a patient over 65, the side rails just automatically went up because we didn’t want you to fall," Grachek recalls. "The whole goal was to prevent falls by imposing barriers. But now I’m getting close to 65, and I don’t want you to put my side rails up, either."

The health care community has moved away from restraint so much that risk managers must reassess some of the fall reduction strategies that were sufficient in past years, she says. When patients are left to be more mobile, more creative fall-and-harm reduction strategies may be necessary, she says.

"A fall-reduction strategy might be, for instance, to have very low beds for residents at risk so that if they fall, they don’t have far to go," Grachek says. "But you need to tailor these strategies to your own setting. Those very low beds might be appropriate in a long-term setting, but in an acute care facility, it might not be feasible to provide care to someone so low to the floor."

Start now to reduce harm from falls

As with surgical fires, Grachek notes that risk managers should address the risk of harm from patient falls whether JCAHO adopts the National Patient Safety Goals or not. And if they are adopted, she says risk managers will be glad they started reducing risk as early as possible. The first step, she says, is to gather data about your current situation.

"It’s all about continuous improvement. The first thing to do is identify your falls rate and then set realistic goals for reducing the fall rate," Grachek says. "You will need to collect data that helps guide your efforts in reducing the severity of falls and multiple falls. When I was in a nursing home setting, we would have weeks with a high number of falls, but that may not have been a high number of individuals falling."

Identifying those high-risk individuals can dramatically reduce the overall number of falls and injuries from falls, she says. Once those patients are identified, an interdisciplinary team should seek solutions appropriate for that particular patient. "Remember that this is not an issue that is just the responsibility of nursing," Grachek says. "You must involve the physician, pharmacy, therapists, anyone involved in the care of the patient."

It also is important to educate patients and their families about the risk of falls, both in the clinical setting and once they go home. Similarly, it is important for providers to communicate about the risk of falls when transferring patients from one facility to another, or from one level of care to another. "Communicate the risk factors, the care plan interventions, the effectiveness of things they have tried, so the receiving organization can follow through on that," she says. "If you are receiving the patient and that information is not offered, ask for it."

Analyze staffing and falls

Grachek also recommends analyzing falls data according to staffing levels. Are there more falls when you use more agency staff? Do falls increase at a certain time of day when staffing levels are low? Are there more falls when unlicensed personnel work with patients?

But also, Grachek recommends caution when assessing whether more falls occur with certain types of personnel, like unlicensed personnel. Even if it turns out that they are involved in more falls, the real responsibility may lie with the licensed personnel who should educate them in avoiding falls and injuries from falls.

"I would be very careful because, in a nursing home situation for instance, 80% of the care is provided by nursing assistants, so it’s not realistic to think that you’re going to have a [registered nurse] or [licensed practical nurse] assisting with the basic activities of daily living," she says. "Those are the people who care for patients all day, and if there are more falls you can’t just conclude that they are careless. You have to look at the training and education you provide those staff and ask if it is adequate."