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An 80-year-old woman was admitted to the hospital following an incident of difficulty walking and slurred speech. She had a history of a seizure disorder for which she was taking medication. She was also receiving treatment for a urinary tract infection. She was admitted to the ICU and her nurse inserted a Foley catheter and attached the necessary monitors. The nurse documented she was at high risk for falls after doing a fall risk assessment. The nurse then left the room to retrieve previous hospital records and the woman crawled to the end of the bed, over the footboard, and fell to the floor. She complained of hip pain and an X-ray revealed a fractured hip. An orthopedic surgeon performed a repair the next morning. The woman was transferred to rehab after several days and then returned to her independent living apartment.
She filed a malpractice claim against the hospital, alleging failure to ensure safety from a fall. The investigation into the harm event revealed that the ICU nurse thought she had activated the bed alarm. However, it was determined that the nurse had recently been out on leave and the ICU beds had been replaced while she was out, and she had not been trained on the new bed alarm system. The experts who reviewed the care were critical of the nurse for failing to understand how to engage the bed alarm and for failing to put in place other fall mitigation strategies based on the patient’s high risk and organizational fall reduction policy. The case was settled with a payment made to woman on behalf of the hospital.
In a review of our malpractice claims, nursing is the most frequently cited service responsible for care at the time of an alleged harm event (16%) and represents 11% of total malpractice costs. Nursing service includes RNs, LPNs, students and nursing assistants. The top allegations made against nursing include failure to ensure safety from falls, improper monitoring, improper medical treatment and medication errors.
All graphs represent malpractice claims reviewed as of 12/31/2022
The number one contributing factor in fall-related nursing claims is the lack of clinical judgment in failing to implement targeted risk strategies to ensure safety from a fall in a patient who has been assessed as at risk for fall-related injuries (89% of claims).
Failure to follow the organization’s policy or protocol is the second most frequent and expensive contributing factor in these fall-related nursing claims as the case above illustrates.
These factors contribute to harm/malpractice claims and are amenable to risk mitigation strategies.
A single harm event may involve multiple contributing factors.
In their 2020 Annual Benchmarking Report, The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss, Candello research shows that the odds of a malpractice claim closing with a payment increased by 145% when the involved organization lacked a formal policy or an existing policy was not followed by the care team. The odds of a claim involving a fall harm event closing with a payment are 204% greater when there is a problem with a policy or protocol compared to fall-related claims without this factor.
Nursing care team members are a highly valuable part of every care team and are directly involved in most aspects of care, so understanding the factors that contribute to fall-related harm is a great opportunity to reduce risk.
Risk reports: Our risk reports analyze malpractice claim data on a variety of topics and specialties, including nursing. Each risk report shares insights to help reduce harm events and malpractice claims. Are you a Constellation client? Sign in to MyAccount to access exclusive customer versions of our risk reports. The expanded reports share actionable insights and strategies you can utilize to help reduce harm events and malpractice claims. After you sign in to MyAccount, follow Risk Resources > Tools & Resources > Publications > Risk Reports. You also have access to a host of Bundled Solutions (in Risk Resources) that cover a wide variety of topics to assist you in your risk mitigation efforts.
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