Musings of a CMO: When patients fall and how to prevent those safety events

Sentinel events are defined as safety events not primarily related to patient’s medical condition that result in death, severe harm (regardless of duration) or permanent harm (regardless of severity). They are called “sentinel” because they require immediate investigation. Last week the Joint Commission (TJC) published their report on 2023 sentinel events [https://tinyurl.com/TJCsentinel2023]. Over 1400 events were reported with falls taking the lion’s share at 48%. All others followed in single digits, including wrong site surgery, retained foreign objects, and assault at 8% each. Of those, 20% resulted in death and 44% in severe temporary harm.

Over 96% sentinel events were self-reported, reflecting the desire of health care institutions to be responsible and transparent. Increased awareness of reporting safety events may be one reason the sentinel events reported to TJC have increased almost 50% in the past ten years from 933 to 1411. Reported sentinel events resulting in deaths were due to suicide or delays in treatment. However, falls were overwhelmingly the main reason for severe temporary harm. In fact, falls have been the majority of reported sentinel events for most every year that I reviewed the data for.

At risk conditions for falls are broad and include advanced age, multiple comorbidities, impaired cognition, gait or mobility, dizziness or weakness after surgery, orthostatic hypotension, confusion from being in an unfamiliar environment, and certain medications. It is no surprise then that US hospitals and healthcare facilities may see anywhere from 700,000 to 1,000,000 falls each year. Falls are not restricted to the elderly frail patient. Any patient of any age is at risk of falling in healthcare settings. In addition to adversely affecting the mental and physician health of patients, falls with injuries can add 6 days to a hospital stay and cost an additional $14,000 to the system in 2015 dollars.

Unfortunately, I have seen some falls of patients that were accurately designated fall risks and had precautions in place. In one instance the patient was able to disable the bed alarm without being noticed by nursing. In a second instance the nurse mistook “bed on” light as the “alarm on” light. The following were reported as the top contributing factors leading to falls with injury in the sentinel events database: inadequate assessment, communication failures, lack of adherence to protocols and safety practices, inadequate staff orientation, supervision, staffing levels or skill mix, deficiencies in the physical environment, and lack of leadership.

The good news is that a large number of falls are preventable. Effective strategies include universal precautions, risk assessments, patient care plans tailored to individual risk factors, and purposeful rounding. It all begins with strong leadership that is committed to developing and fostering a culture of safety. Staff should be educated and sufficiently trained to recognize fall risk and prevent injuries and empowered to hold each other accountable. A multidisciplinary task force should evaluate gaps and help improve processes. In addition to physicians, nursing, and risk management, pharmacy, EVS, application services, care management, security, and social workers may be considered. Fall risk screening should go beyond standardized assessment tools and individualize it each patient. An important element I often see ignored is educating each patient on fall risks, prevention strategies, and setting individual goals. Purposeful rounding helps ensure preventative safeguards are in place and patients are complaint. Finally, all falls should be investigated by involving the care team and gaps and solutions to prevent future falls disseminated across the organization.

Implementing such strategies will lead to reductions in falls but sustained reductions can only be achieved by a change in the mindset of each and every member of the healthcare team. Where every one of us is held accountable and empowered to lead a culture of safety each and every day. We owe this to our patients.

Additional reading: https://tinyurl.com/TJCHospitalFallPrevention

? Chakshu Gupta, MD, MBA [tinyurl.com/cguptaMD]