July 12, 2000
Health care organizations that have experienced sentinel events due to falls have identified the root causes and risk reduction strategies included in this issue. In addition, experts have commented on the events and the related root causes and risk reduction strategies. The Joint Commission offers this information for consideration by hospitals, long term care facilities and behavioral health care organizations in their continuing efforts to reduce the risk of falls of their patients, residents or individuals served.
Fatal Falls: Lessons for the Future
"Maintaining the elders' strength and balance should be on par with maintaining their nutrition and hydration." William H. Thomas, M.D.,
Eden AlternativeTM
Sherburne, NY |
Since the Joint Commission began tracking sentinel events four years ago, the Accreditation Committee of the Joint Commission's Board of Commissioners has reviewed 22 cases related to fatal falls in 24-hour care settings. For each of the events reviewed, a root cause analysis was completed.
Thirteen of the cases occurred in general hospitals with one occurring in a psychiatric unit. Six of the cases were in long term care facilities, one took place in a psychiatric hospital, and two occurred in non-hospital 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, residents or individuals served were elderly, with half being older than 80 years old. One-third of all of the cases involved falling from a bed. Other falls occurred while walking, in the bathroom, or from a commode, gurney or chair. One-third of the total falls were from what an expert called "extraordinary situations." These included falling down a staircase or laundry chute, or from an upper story window, roof or balcony.
Risk Factors
Seventeen of the 22 individuals when they fell 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.
Root Causes Identified by Organizations Experiencing These Events
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. These 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.
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 the following:
- Malfunction or misuse of equipment such as bed alarms.
- Incomplete orientation of new staff.
- Unavailable or delayed medical care.
- Insufficient education of patients, residents or individuals served.
- Inadequate staffing.
- Reduced use of restraints without alternatives.
- Inadequate supervision of caregivers in training.
Risk Reduction Strategies Identified by Organizations Experiencing These Events
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.
The following are additional risk reduction strategies that 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, residents or individuals 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.
"There is a delicate balance between the chance of falls and exposing yourself to risk. If you don't have a certain amount of falls, you are probably overrestricting your patients." Laurence Z. Rubenstein, MD., M.P.H.,
UCLA-Sepulveda Veterans Affairs Medical Center |
Experts' Recommendations
Laurence Z. Rubenstein, M.D., M.P.H., director of the Geriatric Research Education and Clinical Center at UCLA-Sepulveda Veterans Affairs Medical Center, Sepulveda, CA, says extraordinary circumstances of falling down a laundry chute or from a window could be prevented through closer supervision.
Some ways to prevent serious falls from beds are to use beds that are low to the ground and avoid use of full bed rails, according to Rubenstein. Where bed rails are indicated, use of split bed rails are preferable, keeping only the half bed rail at the head of the bed up while leaving the half rail at the foot of the bed lowered. Leaving only the half rail up will prevent residents from rolling out of bed.
William H. Thomas, M.D., founder of the Eden AlernativeTM, Sherburne, NY, recommends that organizations review their fall statistics and look at the average number of medications for those who have fallen and those who haven't fallen. He explains that falls may be caused by adverse reactions such as dizziness leading to loss of balance resulting from taking multiple drugs.