Executive Summary
Falls remain a significant threat to patient safety. Sometimes simple conversations and interventions can reduce falls.
- Communicate with patients and family about fall risks.
- Watch for common causes like medications and dementia.
- Round more frequently than the standard two hours.
Risk managers must not let their guard down on the perennial patient safety concern of falls, looking to the proven methods of prevention and the sometimes simple steps that can have significant effect.
Much of fall prevention relies on helping patients and their family members understand the risk of falls and the potentially severe consequences, says Karen Curtiss, BCPA, founder and executive director of The Care Partner Project, based in Chicago. Part of the mission is to equip patients and families with quick, downloadable checklists that they can follow to help them manage healthcare, along with resources for hospitals to improve fall prevention. Resources are available at https://thecarepartnerproject.org/.
“When we talk about falls, I don’t like to call them errors because that’s a blaming word. I prefer calling them cracks in care or gaps in care,” she says. “The ones that happen most often are the most preventable. The one and only thing we’re ever taught about healthcare is if someone you love is in the hospital or the emergency room, you just show up at their bedside. But none of us really has a clue what to do.”
When family members are educated about falls, they can actually pitch in for patient safety, Brooks says. That education can be as simple as pointing out how much of the equipment and furniture in the room is on wheels and may not provide a reliable hold for an unsteady patient. “It’s a simple thing of just talking about and being aware of the risk for falls, and what will help you, and what won’t,” Curtiss says. “It’s also about giving people permission to ask for help, assuring them there is no shame in asking for help.”
Healthcare organizations should address the defensiveness among care providers in talking about disclosing risks to patients and families, she says. Some of the defensiveness comes from frontline clinicians who feel like, as with so many other patient safety efforts, all the work falls on their shoulders, she notes.
“This defensiveness gets in the way of having good conversations about some very simple and effective patient safety practices,” Curtiss says.
Curtiss’ father suffered a fall that eventually led to his death after complications, and the experience illustrates how conveying simple information can prevent a tragedy. He had been switched to a new medication which could cause dizziness and a drop in blood pressure.
“They could have simply said, ‘Look, this is a new medication and here’s some things that we need to watch out for, and you need to be sure that somebody’s with you when you’re on the move until we see how this medication affects you,’’ Curtiss says. “My dad was a really, really smart person and he was great at following directions. He was such a compliant patient and just that one little conversation would have made all the difference.
Some Patients More Vulnerable
Elderly, impaired, and disabled individuals experience an especially serious risk of falling in the healthcare setting, says Richard F. Cahill, JD, vice president and associate general counsel with The Doctors Company, a malpractice insurer based in Napa, CA. Such incidents often diminish the reputation of the facilities, following negative social media posts, he notes. “Preventable injuries are rarely defensible. Patients, vendors, and others visiting a clinic office, hospital, ambulatory care center, or testing complex who fall and sustain physical harm may initiate litigation to recover monetary damages,” Cahill says. “Not uncommonly, patients may claim that there was inadequate supervision or support by clinic personnel prior to the incident constituting medical negligence. A lawsuit involving such allegations may thereby trigger the provider’s professional liability coverage.”
Alternatively, an individual who sustains injuries from a fall may allege that the property was inherently dangerous or defective, which may have been avoided through the implementation of simple measures, he says. In this situation, the general liability policy for the clinic would ordinarily respond to provide counsel for defending the action and pay the indemnity in the event of a settlement, adverse jury verdict, or arbitration award, he says. Cahill says healthcare providers and facilities are strongly encouraged to undertake these proactive measures to prevent falls from occurring in the first place, thereby limiting potential financial exposure:
- Routine inspections of equipment, including elevators, escalators, treadmills, examination tables, support railings, public restrooms, and common areas, as well as the overall condition of the premises, will help to identify problems that can be corrected in a timely manner.
- Periodic ergonomic risk assessments by third-party experts promote greater safety and often achieve consistency with prevailing community standards.
- Records detailing maintenance efforts, including sweep sheets and repair orders, generally will demonstrate due diligence and a concern for the well-being of guests attending the premises, enabling counsel to present a more defensible case to the finder of fact, should the matter proceed to trial or hearing.
- Similarly, medical offices should consider developing a protocol for assessing patients, especially the elderly, infirm individuals, or persons presenting with a physical limitation, disability, or other impairment at the earliest available opportunity to be better prepared to prevent a fall from occurring. Offices should appropriately document the medical records of any individuals so assessed.
“Office policies related to facilities maintenance and patient assessments, as well as staff members’ implementation of those policies, should be periodically audited for compliance and updated as necessary to help ensure best practices are being followed,” Cahill says. “It is also recommended that healthcare offices maintain a post-fall protocol detailing steps to be implemented to ensure that prompt medical care is provided.”
New Environment Risky
Patients placed in any new environment with unfamiliar surroundings will be susceptible to a certain amount of confusion, which can lead to falls, says Anna ten Napel, PhD, RN, NP, vice president for regulatory affairs and performance improvement with Catholic Health in Long Island, NY.
Also, the units they are admitted to often are busy hubs, requiring the attention of staff, who then are not always able to monitor each patient’s needs every minute, she says. Additionally, many patients tend not to wait for staff assistance getting out of their beds or needing to walk or use the facilities, she says. These factors combine to increase the risk of an untoward event, such as a fall.
“At Catholic Health, we’re addressing these issues upfront by carefully explaining that a hospital environment is different than their home and providing guidance on how best to avoid any accidents,” Napel says. “We ask them to recognize their vulnerabilities and review and sign a Fall Prevention Agreement. This fosters the patient’s active participation in our safety strategy.”
Catholic Health looks at each patient’s individual needs, screening all for fall risk. It has invested in tele-sitter technology to keep a watchful eye on patients and is sharing best practices with other hospitals across the country to reinforce its fall prevention programs, Napel says.
“Our own best practice tools are built into our electronic medical record platform, providing alerts to notify staff of patients who are categorized as high risks for falls,” she says. “That prompts us to pay closer attention to those patients’ needs. Most recently, we’ve introduced micro-learning, where our staff watch short vignettes that reinforce our grasp of preemptive fall prevention.”
Napel notes that there is no single strategy to prevent falls. A multifaceted, multilayered approach to ensure safety, always recognizing that each patient will have their own specific needs, will yield the best results in avoiding patient falls, she says. “As falls can be devastating, it is critical that all resources be applied in the prevention of patient falls,” she says. “Innovation and technology are certainly vital, and yet, at Catholic Health, we always come back to listening to our patients, really engaging with them to understand their needs, and making them partners in their own care.”
Follow Prevention Strategies
Falls always will be a risk in healthcare settings because patients are more frail than other adults in the community, says Ken Sha, program director at Excel at Woodbury for Rehab and Nursing in Woodbury, NY. They often have chronic conditions, such as osteoporosis, balance, vertigo, heart and lung conditions, and difficulty walking along with issues with memory, active daily leaving, and being in a new environment, he explains. Common causes of fall are muscle weakness, medications, and new onset of diagnosis, Sha says.
The most effective prevention strategies include multiple factors, such as medications and rehab services — physical, occupational, speech, and recreation therapy. In addition, Sha recommends these fall-prevention strategies:
- Assess patients after any fall to identify risk factors and medical conditions.
- Educate staff on environmental safety.
- Have proper, durable medical equipment in place, such as grab bars, raised toilet seats, lower bed heights, and proper ambulation devices.
- Use appropriate devices, such as bed alarms and chair alarms, for cognitive issues.
- Incorporate exercises and rehabilitation to improve patient strength, static and dynamic balance, endurance, and walking abilities.
- Anticipate patients’ needs.
- Maintain a toileting schedule.
- Incorporate group activities for supervision and education on safety and proper body mechanics.
Sha advises against the use of physical restraints because studies show that they do not reduce falls.
Use Appropriate Rounding
Falls are an unfortunate outcome that are never fully preventable, but they can be mitigated, says Christopher E. Brown, JD, partner with the Kaufman Dolowich law firm in Orlando, FL. In the hospital and long-term care setting, the best prevention strategies are to assess the patient upon admission to the facility, familiarize the patient with the environment, maintain a call light, and ensure the patient is competent in the call light’s use, he says. It also is useful to keep hospital beds and wheelchair brakes in the locked position at all times, use non-slip footwear with the patient, and ensure handrails are in place in all private bathrooms, he says. Appropriate rounding by hospital personnel also can go a long way to avoiding these falls. While the industry standard is to round every two hours, more frequent rounding and patient observation can avoid situations where an individual feels compelled to move without assistance, Brown says.
“In regard to liability, it is important and necessary to document all assessments and interventions that have been implemented for the patient. This needs to be done immediately and has little to no effectiveness if completed after a fall has occurred,” Brown says. “Rounding, including the time and individual who performed the service, should also be documented contemporaneously in the medical chart.”
Sources
- Christopher E. Brown, JD, Partner, Kaufman Dolowich, Orlando, FL. Telephone: (407) 789-0230. Email: [email protected].
- Richard F. Cahill, JD, Vice President and Associate General Counsel, The Doctors Company, Napa, CA. Telephone: (800) 421-2368.
- Karen Curtiss, BCPA, Founder and Executive Director, The Care Partner Project, Chicago. Telephone: (847) 208-6074. Email: [email protected].
- Anna ten Napel, PhD, RN, NP, Vice President, Regulatory Affairs and Performance Improvement, Catholic Health, Long Island, NY. Telephone: (716) 706-2112.
- Ken Sha, Program Director, Excel at Woodbury for Rehab and Nursing, Woodbury, NY. Telephone: (516) 692-4100.
Risk managers must not let their guard down on the perennial patient safety concern of falls, looking to the proven methods of prevention and the sometimes simple steps that can have significant effect.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content