Prevention of patient falls - A case study

Prevention of patient falls - A case study

Quality in Health

Prevention of patient falls e A case study

Gaurav Loria a,b,*, Ankita Bhargava c

aCoordinator Quality, Apollo Group, Jubilee Hills, Hyderabad, IndiabNational Head Quality, Jubilee Hills, Hyderabad, IndiacExecutive Quality, Apollo Hospitals, Hyderabad, India

a r t i c l e i n f o

Article history:

Received 23 January 2013

Accepted 18 February 2013

Available online 28 February 2013

Keywords

Patient safety

Precautions

Morse fall risk scale

Root cause analysis

a b s t r a c t

Fall-related injuries can be some of the most common, disabling, and expensive health

conditions encountered by adults, especially older adults. According to researcher Janice

Morse, approximately 14% of all falls in hospitals are accidental, another 8% are unantic-

ipated and 78% are anticipated falls. Guideline to prevent falls in the hospital has helped to

bring down the numbers and improve patient safety.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Patient falls: introduction

Patient falls have been identified by the Joint Commission as

one of the top five sentinel events for home care organizations

in its December 2003 sentinel event report.1 According to the

researcher Janice Morse, approximately 14% of all falls in

hospitals are accidental, another 8% are unanticipated and

78% are anticipated falls.2

Fall-related injuries can be some of the most common,

disabling, and expensive health conditions encountered by

adults, especially older adults.

The number of persons above the age of 60 years is fast

growing, especially in India. India as the second most popu-

lous country in the world has 76.6million people at or over the

age of 60, constituting above 7.7% of total population. The

problems faced by this segment of the population are

numerous owing to the social and cultural changes that are

taking place within the Indian society.3

Every year thousands of cases of patient falls are reported

which majorly comprise of the elderly.

Main reasons for falls:

� Lack of staff communication, orientation and training

� No proper patient’s assessment

� Physical environment

� Care planning

� Organization culture

Vulnerable patients are mainly those who are more

susceptible to a fall when admitted in a hospital like

patients above 65 years old (geriatrics), children less than

16 years of age (pediatrics), patients who are physically/

mentally challenged or patients who cannot perform acts of

daily living.

For effective management of such patients, five balancing

steps are required. These are:

* Corresponding author. Coordinator Quality, Apollo Group, Jubilee Hills, Hyderabad, India.

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/locate/apme

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0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2013.02.006

1. Determine the vulnerability of thepatient and identify them

2. Patient First program or a special program to be

implemented

3. Frequent assessments and reassessments

4. Specific therapy

5. Supportive care

Team composition: Quality Systems and Nursing in

charges.

2. Objectives of study

� To study the trend of patient falls in the hospital

� To trace the causes of falls

� To make necessary interventions to reduce the fall rate

� To improve patient safety by introducing practices to pre-

vent falls

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3. The process flow/guideline for fallprevention

Fall and fall-related injury outcome measures

4. Assessment parameters

1. Number of patient falls per month

2. Patient fall rate

3. Percentage of patients who were classified under ‘low risk’

but had a fall

Key tasks: Modified Morse fall Risk Assessment was

made a part of the admission record. A separate sheet was

also designed and circulated in all Outpatient and Day

Care Areas to ensure the assessments of the patients.

Training of the nursing team was done by the Quality

Team.

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Interventions annexure4

Interventions High Moderate Low

Patient

education

- Orient patient to surroundings and hospital routines

- Orient patient about the call bells andmake sure patient

is able to use it

- Instruct patient to call for help before getting out of bed.

- Instruct the patient and family about the significance of

fall prevention program

- Teach patient to use grab bars

- Discuss toileting needs of the patient and implement

bowel and bladder program if necessary

- Instruct the patient on side effects of drugs

- Orient patient to surroundings and hospital routines

- Orient patient about the call bells andmake sure patient

is able to use it

- Instruct patient to call for help before getting out of bed

- Instruct the patient and family about the significance of

fall prevention program

- Teach patient to use grab bars

- Orient patient to surroundings and hospital routines

- Orient patient about the call bells andmake sure patient

is able to use it

Nursing Place Patient First Card bed side

Side Rails Always Up

Lock all moveable

Equipment before transferring

Provide adequate lighting

Place Bed Pan/urinal within easy reach

Position the bed at low level with brakes locked/position

the foot stool in place

Communication Board Placement

Place assist devices within reach

Develop a schedule for turning and positioning

Increase frequency of patient rounds

Instruct housekeeping supervisor to keep pathway clear

from obstacles and keep toilet floor dry

Consider obtaining doctors order for physiotherapy

consult

Place Patient First Card bed side

Lock all moveable equipment before transferring

Provide adequate lighting

Place Bed Pan/urinal within easy reach

Position the bed at low level with brakes locked/position

the foot stool in place

Place Patient First Card bed side

Side Rails Always UP

Lock all moveable equipment before transferring

Provide adequate lighting

Documentation Vital signs recording as per orders

Assess patient’s condition in his ability to do acts of daily

living (ADL)

Physical restraints ordered

Physical therapy as ordered

Document the falls in incident report form and inform

Medical Head

Vital signs recording as per orders

Assess patient’s condition in his ability to do acts of daily

living (ADL)

Physical restraints ordered

Physical therapy as ordered

Document the falls in incident report form and inform

Medical Head

Vital signs recording as per orders

Assess patient’s condition in his ability to do acts of daily

living (ADL)

Physical restraints ordered

Physical therapy as ordered

Document the falls in incident report form and inform

Medical Head

Medication Minimize the use of medications that alter mental status.

Use alternatives to sleeping medications

Dispense diuretics before afternoon/evening

Treat pain

Screen and treat for hypoxia

Assess the clinical status of delirious patients to rule out

reversible etiologies

Promote mobility and fitness

Minimize the use of medications that alter mental status.

Use alternatives to sleeping medications

Dispense diuretics before afternoon/evening

Minimize the use of medications that alter mental status.

Use alternatives to sleeping medications

Dispense diuretics before afternoon/evening

Reassessments Every hour Frequent Every day

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5. The falls project

The project was implemented as a pilot for a week wherein

few departments were covered. The success in the pilot

project helped us to implement the same initiative all across

the hospital.

Data collection: The patient fall-related incidents

were reported to the Quality Team by Incident Forms.

These forms were the source of information of the falls

which were further analyzed through Root Cause Analysis

(RCA).

Sustainability initiatives: The completion of the form was

also checked through the Wake Up Call Rounds and reported

to theNursingHeads. Continuous surveys and surprise checks

for documentation compliance and equipment safety were

carried out to ensure safety.

Patient and Family Education (PFE) was an integral part of

the whole process. Handbooks were introduced which helped

in explaining the patients and attendants better.

Improvement: Before taking up the project, our patient

falls were about 7 in the first six months (JaneJun 2011).

With vigorous training of the staff the incidents reporting

also improved and the number of falls reported was high

in the next six months (JulyeDec 2011). The following

six months (JaneJun 2012) the numbers came down dras-

tically which was a result of PFE and vigorous staff

training.

Findings/Results:

Findings JanuaryeJune 2011 JulyeDecember 2011 JanuaryeJune 2012

Number of falls 7 14 4

Reasons � Patient fell in bathroom

(no assistance)

� Patient ambulating to bathroom

� Patient fell from bed

� Patient’s physiological condition

� Broken chair

� Patient fell in bathroom (wet floor)

� Patient fell in the bathroom

(no assistance)

� Patient slipped in the room

� Patient’s physiological condition

� Patient’s physiological

condition

� Patient fell from the bed

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The number of patient falls per 1000 discharges were found

to be well within the benchmarked limits.

It was also found that of all the patients who had a fall

21% were already categorized by the nursing staff as one

vulnerable to fall while 42% at a moderate risk and 37% at a

low risk.

The major reasons for fall were also analyzed after

completing a detailed review of every fall. The major reasons

ranged from patient’s fall from the bed to his physiological

condition to a fall in the bathroom at night.

It was also observed that maximum patient falls happened

at night (between 1 am and 4 am) when patients try to go

unassisted to the toilet without informing anyone (even the

attendant).

6. Conclusion

� The implementation of the guideline has brought some

important outcomes.

� The number of falls have been varying from 0 falls to 5 falls

per month. The staff has been trained on prevention and

management of falls. The Patient and Family Education has

been stressed upon with the bilingual patient education

booklets and flip charts.

� Patient falls have happened due to various reasons of which

patient falls in thebathroomandphysiologicalconditionof the

patient have been the major causes. These have been taken

seriously and brought to the notice of the patient caregivers.

� Adequate assessment of the fall risk has been stressed upon

to reduce the risk and training is being given to ensure fall

prevention.

� To reduce such patient falls, patients as well as attendants

are being educated using flip charts.

� Wehave also conducted training programs and competency

assessments for the entire staff of the hospital.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Reducing the Risk on Falls in Your Health Care Organization.Joint Commission Resources http://www.patientsafety.gov/SafetyTopics/fallstoolkit/index.html.

2. Preventing Patient Falls e Establishing a Fall InterventionProgram (2nd ed.) Janice M. Morse.

3. Falls in older people. National/regional review India. Dr. B.Krishnaswamy, Professor and Head; Dr. GnanasambandamUsha, Assistant Professor, Department of Geriatric Medicine,Madras Medical College and Government General Hospital,Chennai City, Tamil Nadu State, India.

4. http://www.downstate.edu/patientsafety/falls.html.

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