Failure to ensure safety from falls
A 70-year-old woman was taken to the local hospital after falling at home. In the emergency department, X-rays revealed a fractured left ankle, and she was admitted to the hospital for surgery. Her nurse assessed her as a level II fall risk. The following morning, an orthopedic surgeon surgically repaired her fractured ankle and because of her level of pain postoperatively, he admitted the woman to the hospital for pain control.
Later that evening, following PT, the woman got out of bed without assistance to use the bedside commode and fell. She was found on the floor by her nurse. According to the nursing notes and the patient’s testimony, she urgently needed to use the commode and could not locate her call light, so she grabbed the commode, attempted to stand, the commode tipped over and she fell, landing on her right hip. She immediately complained of right hip pain.
The orthopedic surgeon ordered an X-ray, which revealed a displaced and comminuted right subtrochanteric femoral fracture. The next morning, the orthopedist surgically repaired the hip fracture and four days later discharged the patient to a nursing home for rehab. After a week of rehab, she was discharged back to her home. Six months later, she complained of increasing pain in her right hip. She went on to require two more hip surgeries to repair a nonunion of her hip fracture.
The patient filed a malpractice claim against the hospital, alleging failure to ensure safety from falls.
The defense of this case was hampered by the failure of the nursing staff to follow hospital policy for a patient assessed at a level II fall risk and the inconsistent use of the fall risk assessment tool. The nurses inconsistently scored this patient’s level of fall risk and failed to change the scoring when the patient developed loose stools and urgency. During the investigation of the event, the patient said that she had been instructed to use her call light for assistance, but she could not locate it. She also said that she shouted for the nurse, but no one responded. Because of her urgency, she got up to use the commode without assistance. She also said that had the bedside alarm gone off, she would have just sat back down on the bed and waited for a nurse to respond to the alarm. The malpractice case was settled against the hospital.
In our analysis of Constellation malpractice claims originating in the hospital settings, falls and fall-related injury represent 10% of claims and 4% of costs. Our claim data shows that 71% of falls resulting in hospital claims occurred in the patient’s room and account for 81% of hospital costs. The top contributing factors to hospital fall claims include errors in clinical judgment (critical thinking skills) related to implementation of fall reduction strategies (e.g., failing to follow the care plan for an at-risk patient) and failure to have or follow the organizational policy relating to fall reduction.
How do you know if your fall reduction program is effective?
The only way to know if your fall reduction program is effective at reducing fall-related injury is to objectively analyze it. Constellation’s Fall Risk Assessment tool can help your organization identify gaps in best practices to mitigate falls and fall-related injury. Sign in or register at ConstellationMutual.com and navigate to Risk Resources > Bundled Solutions > Hospital Risk to access our Fall Risk Assessment.
The online risk assessment consists of 40 questions that assess your fall reduction program and provides immediate feedback with recommendations to improve.
Another way to assess the effectiveness of your program is to review fall-related metrics. Ask these questions:
- What is our fall rate and is it decreasing after implementing best practices?
- How well are our tools working? Are we good at predicting a person’s fall risk?
- Are we reducing fall-related injuries?
How to improve your fall reduction program with internal auditing
“A good way to evaluate performance is to utilize internal audits. These prove to be vital when monitoring adherence to policies and procedures.”Michael Turturici, Constellation Senior Risk Consultant
- Do you audit patient medical records to assess the completeness of your fall risk assessment tools used by team members?
- Do you audit the same patient’s medical record across multiple shifts to identify gaps in consistency in how your team evaluates fall risk for the same patient? (inter-rater reliability).
- Do you audit medical records to determine how well patients are being assessed post-medication administration, and are these findings updated on the fall risk assessment?
- How often do you review post-fall documentation to ensure all team members capture the information necessary for a complete fall investigation?
While this may seem to be a documentation audit, it is also an assessment of how well your team is implementing your fall reduction program. An audit can provide valuable insight into how well your teams understand and implement your fall mitigation strategies and how well they understand how those strategies work together.
Internal auditing is also useful to monitor performance improvement plans borne out of root cause analyses of patient falls. To improve your team’s performance:
- Post internal audit results and fall-related metrics so that teams can see how their performance affects patient outcomes.
- Periodically re-educate team members on your fall reduction policy, reduction strategies and documentation standards.
- Ensure team members are educated on how to perform and document a fall risk assessment using your validated assessment tools.
- Educate patients and families about individual fall risk and their role in fall reduction. Expectation setting and shared decision-making are crucial to mitigating fall-related injury.
Sign in or register at ConstellationMutual.com and navigate to Risk Resources > Bundled Solutions > Hospital Risk to access our Fall Risk Assessment and other resources to improve your team’s performance.
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