Sentinel event tracking reveals fall injury pattern
The elderly top the list
Since the Joint Commission Commission on Accreditation of Healthcare Organizations began tracking sentinel events four years ago, the accreditation committee of its Board of Commissioners has reviewed 22 cases related to fatal falls in 24-hour care settings.
Thirteen of the cases occurred in general hospitals, with one occurring in a psychiatric unit, according to a recent report from the Joint Commission. Six of the cases were in long-term care facilities; one took place in a psychiatric hospital, and two occurred in nonhospital behavioral health care organizations. Half of the deaths following the falls were the result of head trauma, usually with subdural hematoma. Falls determined to be acts of suicide were not included in this review of cases. However, in some of the occurrences, suicide or homicide could not be ruled out as a factor.
Most of the patients and residents served were elderly; half were older than 80. One-third of all of the cases involved falling from a bed. Other falls occurred while walking, while in the bathroom, or while using a commode, gurney, or chair. One-third of the total falls were from what an expert called "extraordinary situations." Those included falling down a staircase or laundry chute or from an upper story window, roof, or balcony.
When they fell, seventeen of the 22 individuals had an altered mental status due to chronic mental illness or acute intoxication. History of prior falls, use of sedation, and anticoagulation were frequently associated risk factors. Other risk factors included a recent environmental change and urinary urgency. A disproportionate number of falls occurred on nights, weekends, and holidays.
For the 22 cases, the health care organizations identified root causes related to the care processes, caregivers, environment of care, and organizational culture. More than half of the organizations identified communication issues among caregivers as a root cause. Those included failure to communicate information during nursing report, shift changes or a transfer from a hospital to a nursing home, caregivers not documenting changes in conditions in the medical record, and families’ inadequate communication about conditions and history of falling.
Improve staff training
Forty-one percent of the organizations identified incomplete patient assessment and reassessment, an incomplete plan of care or lack of protocol, and environment-of-care issues such as the design of windows, door locks, and nursing stations. The other root causes included malfunction or misuse of equipment such as bed alarms, incomplete orientation of new staff, unavailable or delayed medical care, insufficient education of patients and residents served, inadequate staffing, reduced use of restraints without alternatives, and inadequate supervision of caregivers in training.
Organizations that experienced the falls identified risk reduction strategies to reduce the likelihood of reoccurrence of the events. Eighty-six percent suggested improving staff orientation and training. Other strategies recommended were to revise and implement a fall risk assessment process and to implement a formal fall prevention protocol.
How to reduce risk
The following additional risk reduction strategies were identified:
• installing bed alarms or redesigning bed alarm checks and tests;
• installing self-latching locks on utility rooms;
• restricting window openings;
• installing alarms on exits;
• adding fall prevention to education of patients and residents served and their families;
• improving and standardizing nurse call systems;
• using "low beds" for those at risk for falls;
• revising staffing procedures;
• counseling individual caregivers;
• revising the competency evaluation process.
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