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An 81-year-old woman became dizzy, lost her balance and fell, hitting her head on her kitchen counter. An ambulance brought her to the local hospital emergency department (ED) for evaluation. The ED physician ordered X-rays of the C-spine and a CT scan of her head. While in the radiology suite she requested to use the bathroom. The radiology tech placed her on a bedpan while still on the radiology table and went over to the other side of the room behind a wall to give the woman privacy.
The woman reached to the side of the table to support herself, slipped off the edge of the table and fell to the floor. She suffered contusions to her right leg and had lacerations above both eyes that needed sutures. She was admitted to the hospital for monitoring. Her family filed a malpractice claim against the hospital alleging failure to ensure safety from a fall in a patient with a known fall risk.
Failure to ensure safety, driven largely by fall-related injuries, is the fourth leading malpractice allegation made against hospitals.In our analysis of Constellation malpractice claims, nursing care teams were the primary responsible clinician for this category of claim allegations and most falls were found to occur in the patient’s room. However, falls also occurred in radiology, physical therapy/rehab, ED and surgery.
Top locations of fall-related hospital harm
Top contributing factors
Common in these hospital harm events were patients assessed at high risk of a fall being left alone for toileting privacy. These events occurred regardless of assessment of being at high risk for a fall, or organizational policy.
The top contributing factors involved in hospital fall-related harm events are:
Failure to ensure safety by implementing fall interventions
Policy not followed or absent
Patient assessment and monitoring issues
Communication breakdowns between the patient/family
“Care team members must be empowered to prioritize patient safety over privacy and coached to empathetically share safety concerns with reluctant patients and family members.”
Betty VanWoert, Senior Risk Consultant at Constellation
Patient monitoring during this vulnerable time can be critical to fall reduction strategies. Patient assessment for fall risk should also be ongoing rather than only on admission. Otherwise, as patient conditions change and medications are adjusted, the risk of falling may escalate undetected. Fortunately, contributing factors are amenable to risk mitigation strategies.
How to reduce fall-related harm in the hospital:
Better understand your hospital’s fall-related harm events by taking our Fall Risk Assessment.
Provide initial and annual training on fall risks, reduction strategies, and related policies, including bedside skills for assessment, monitoring and communication.
Promptly report all falls with injury to Constellation for expedited access to risk consultation and HEAL services.
Track and trend fall event causes and contributing factors to identify vulnerabilities in your fall reduction program, policies and protocols.
Analyze fall-related injury events using a tool like IHI’s RCA2 tool to detect causal and contributing factors and then redesign safer care processes.
The HEAL Prepare Toolkit
Our HEAL Prepare Toolkit helps your organization prepare for and respond to fall-related harm events. Unit 2, Event Response, can help you understand how contributing factors such as poor critical thinking skills, failure to follow organizational policy and breakdowns in communication contributed to the fall event.
Start your journey by taking the HEAL Assessment and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) patient communication, and (4) moving forward. Sign in to ConstellationMutual.com to access the HEAL Prepare Toolkit and HEAL assessment found in Risk Resources.
Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.