Quality in Health

PATIENT falls is an important quality determinant and itsprevention poses a significant challenge for creating a safeand caring environment in a healthcare setting. A patientfall not only reflects on the level of coordination amongstthe various categories of healthcare providers, but alsoindicates the existing gaps in the service delivery process.

The present study analyses the incidents of patient falls,with an ultimate goal of reducing and eliminating allpreventable falls.

MATERIAL AND METHODS

A retrospective analysis was done of all patient falls inIndraprastha Apollo Hospital, New Delhi from April 2004to August 2004. Prior to the study, all employees wereeducated about the importance of reporting any patient fall.The "blameless policy" of the organization was reinforcedto further increase all reporting. A “patient incident” formhad been introduced in the organization and employeeswere instructed to report falls on this form. The nursingdepartment collected the patient incident forms and a seniorlevel nurse was deputed within 24 hours to analyze theevents leading to the fall in each case. Data was compiledon a monthly basis and reported to the Division ofInnovations for Clinical Excellence (DICE). The DICETeam analyzed all forms and trends were plotted. Trendswere compared to other parameters in an effort to detect anycorrelations with obvious and not so obvious causes. Amultidisciplinary team was organized to do a root causeanalysis (RCA) of patient falls and their recommendationswere noted. The team consisted of senior and juniormedical staff members, nursing staff, patient services,engineering, housekeeping and security personnel. The

ELIMINATING PATIENT FALLS FOR ACHIEVING THE SAFETY GOAL

Umesh Gupta+, Pritindira+†, Anupama Sharma+†, Anjula Bansal#, Neha Jain#, Anupam Sibal*

Department of Vascular Surgery†, Team leader JCI DICE+, Executive DICE+†,Resident DICE#, Director Medical Services & Senior Consultant Pediatric Gastroenterologist*,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi-110044, India.

Correspondence to: Dr.Umesh Gupta, Consultant Vascular Surgery, Indraprastha Apollo Hospitals,Sarita Vihar, Mathura Road, New Delhi 110044, India.

E-mail: uhgupta@hotmail.com

Patient falls is the leading cause of patient incidents in an acute care setting. Patient falls has been attributedto many factors including trauma, debilitating disease, environmental hazards, age, mental status, length ofhospital stay and gender. The present study was carried out to evaluate patient falls in our hospital and torecommend strategies to reduce such incidents.

Key words: Patient falls, Safety goal.

data, trends, correlations, RCA and the recommendationswere presented to the Quality Steering Committee and therecommendations were then adopted.

RESULTS

Of the total number of patient falls, reported during thestudy period, from April to August 2004 (Fig. 1), almost50% of falls had occurred in patients who were aged 65years and above i.e., they belonged to the vulnerablecategory (Fig. 2).

The majority of falls occurred in patients while trying toget out of bed, using the toilet, while changing positionduring sleep and in certain cases suddenly losingconsciousness. Around 52% of these falls occurred fromand near the bed itself (Fig. 3).

The numberof incidences in the Tower 1 of theHospital complex was more than those occurring in theTower 2. This was attributed to two factors. The first factorbeing, more number of beds in Tower 1 area and secondfactor being the higher placement of new nurses in Tower 1area as compared to Tower 2 (Figs.4, 5).

The nurse bed ratio in both Tower 1 and Tower 2 isnearly the same; hence the comparison indicates that thereis no correlation of the fall incidents with the nurse bed ratio(Fig. 6).

DISCUSSION

By definition [1], “A ‘fall’ is an untoward event whichresults in the patient coming to rest unintentionally on theground or other lower surface”.

The numerous factors that can precipitate falls can be

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Fig. 1. Patient falls - Monthly incidence.

Fig. 2. Number of bed falls with respect to age group.

Fig. 3. Micro presentation of factors responsible for patientfalls.

Fig. 4. Patient falls vs number of beds.

Fig. 5. Patient falls vs new nurse joiners.

Fig. 6. Patient falls in T1, T2 vs bed nurse ratio.

classified into:

I. Patient factors

(a) Drug side effects: Medications that act on the CNS(sedatives and tranquilizers) and CVS increase therisk of the patient's falling.

(b) Poor mobility: Risk factors include a weak orimpaired gait, weakness, and decreased mobility oflower limbs, poor coordination and improperbalancing.

(c) Altered sensorium: The altered mental state ofpatients which is commonly reported as confusion

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or disorientation, is a significant factor forincreasing a patient’s risk of falling

(d) High fever: Patients experiencing high fever arealso prone to fall.

II. Unsafe environment

(a) Side rails not in place: It was found that in someincidents of falls, side rails were either not presentor were not put up.

(b) Side rails lacking as per specifications: Certainfalls occurred when there was incorrect fitting andpositioning of the side rails.

(c) Loose wires: Wires of certain portable equipmentare potentially hazardous in such situations whenthese are connected to electric sockets that weresituated far away from the patient.

(d) Lack of support accessories in washrooms:Supporting bars are absent both outside as well asinside the washroom areas.

(e) Poor lighting: Inadequate lighting in ward areascan lead to fall incidents.

(f) Distant toilet: The distance between the patient bedand the toilet was more in certain cases.

(g) Wet washroom floors: Slippery floors increase therisk of falling

(h) Call bell not functioning: Patient might try to moveout of the bed unassisted if the call bell does notfunction.

(i) Overcrowding: Crowding or cluttering in patientareas increases the chances of tripping and falling.

III. Lack of supervision

(a) Patient left unattended: There have been instanceswhen the patient was left alone without any relativeor staff.

(b) Inadequate staff/attendant to assist patient: Forambulatory patients, single attendant or staff issometimes not enough to prevent the patient fromfalling.

IV. Improper patient education

(a) Lack of instructions to not to get out of bed withouthelp: At times the patient is unaware of the fact thathe/she might fall due generalized weakness or sideeffect of thme medication.

(b) Lack of information regarding the use of assistivedevices: It was observed that patients got out of bedon their own and did not use the call bell system tocall the nurse.

We performed a Root-Cause Analysis of patient falls in

our Hospital. For this, a multidisciplinary committee wasformed which gave their recommendations for decreasingthe number of patient falls. The major recommendation ofthe committee was to introduce a falls preventionprogramme called “The Safety First Programme”, aimed atminimizing individual patients’ risk of falling.

The “Safety First” program is a multi disciplinary andmultitier programme that starts with identification of thosepatients who are at greatest risk of falling. The followingpatients were identified as vulnerable:

(a) Age group of 65years and above.(b) Age group of 15 years and below.(c) Patients who cannot perform activities of daily

living (ADL).(d) Physically or mentally challenged.

Nursing and para-medical staff identified those patientsusing this simplified definition of vulnerable patients.Patients outside of this definition but still vulnerable to fallsare also identified by the clinician in an Inter DisciplinaryTeam. Such patients include:

(a) Patients on Cardiovascular medication.(b) Patients on medication affecting Central Nervous

System.(c) Patients with high grade fever (102° F).(d) Patients who have been received from the ICU, for

the initial few days.

ICU patients are not included as all ICU patients are atrisk for falls and receive a high level of individualizednursing care in any case. The ‘Safety First Programme’ isdesigned to identify patients on General Care areas only.

This programme consists of various interventions forenabling a safe hospital stay for the patient. The “SafetyFirst” kit consists of a visual signage of ‘Safety First’,which is put on patient’s bedside in order to enable easyidentification of the patient (Fig. 7). The Guest RelationsOfficer conducts the safety education session for the patientand relatives.

The kit also consists of a brochure containing hospitalguidelines for a safe stay as well as home safety tips such asasking for help from the staff; locking the brakes on thewheel chair before sitting down or standing up; asking staffto place needed items like water; telephone within reachputting up on patient bed; using call bell when needed;wearing slippers with non-skid soles; climbing stairsslowly; using non-skid mats in bathrooms; etc. (Fig. 8)

The nursing staff completes the “Patient Care Plan” inthe kit, which consists of risk assessment, documentationand implementation of strategies to address the deficits.

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(f) Instructing male patients prone to dizziness to voidwhilst sitting.

(g) Having grab bars near and inside washrooms,which are fitted vertically rather than in ahorizontal position.

The Post Fall Protocol consists of filling up of theincident form and filing of the same with the Head of theMedical Services. It must be mentioned here that reportingof fall incidents is totally a blame free approach in thishospital.

The other highlight of our study has been the correlationbetween new nurses and the number of falls. This findingemphasizes the need to have a strong orientationprogramme for all new staff and the inclusion of “SafetyFirst” in such an orientation programme.

Adoption of the “Safety First” programme is expectedto have many benefits. We hope to achieve a reduction indirect patient care costs, risk management and increase inpatient satisfaction.

CONCLUSION

The over-arching principle that guides the interventionchoices for creating a safe environment is the principle ofmaintaining the highest quality of life possible whilestriving for a safe environment and practices. Risk taking,autonomy, and self-determination are supported,respected, and considered in the plan of interventions.Hence, increased vigilance by the care team through acollaborative process is essential to prevent patient falls.Patients and relatives also need to be regularly reminded ofthe safety issues concerning them.

REFERENCES

1. Morris EV, Isaacs B. The prevention of falls in a geriatrichospital. Age & Ageing 1980; 9: 181-185.

2. Wilson E. Preventing patient falls. AACN Clinical Issues1998; 9(1): 100-108.

Other interventions(2)

(a) Keeping the bed on low when not performingphysical care.

(b) Locking wheels into position on beds.(c) Placing patients with urgency near toilets.(d) Checking patients who are receiving laxatives and

diuretics.(e) Assisting at risk patients to the toilet routinely.

Fig. 8.

Fig. 7.