Patient falls are the most commonly reported adverse event in hospitals. Every year in the United States, hundreds of thousands of patients fall in hospitals, and 30 to 50 percent of these events result in injury. So why shouldn’t we work as hard as we can to prevent falls?
There’s no question that preventing falls is important. The problem is that when we treat all falls as if they’re the same, we fail to distinguish between preventable versus unpreventable falls or between types of falls. Screening tools tend to identify patients who are likely to fall again and screen for risk factors that are associated with anticipated physiological falls. But what about unanticipated physiological falls? What about accidental falls?
When we focus exclusively on fall risk scores, we place too much importance on a number and the level of fall risk. This can lull us into thinking we’re doing all we can for patients. We’re not. Instead, we must go beyond standard fall risk screening and conduct a multifactorial fall risk assessment, as well as an injury risk assessment so that we can prevent patients from both preventable falls and resulting harm — including death. In other words, we must focus not just on people who are at risk of falls, but people who are at risk of injury if they fall. It may be a subtle distinction, but it’s an important one — it allows us to protect patients from injury for any type of fall.
Taking a Population-Based Approach to Prevent Harm from Falls
In September, the Joint Commission released a Sentinel Event Alert on preventing patient falls and fall-related injuries. The most compelling aspect of the alert its emphasis on determining injury risk earlier in the patient admission assessment, care planning, and overall management of a patient safety program.
The VA National Center for Patient Safety developed the first national toolkit to focus on fall injury reduction in 2004, with updates in 2014. For over a decade, my VA’s primary focus has been to protect people from injury, because you simply can’t prevent all falls. People get out of bed without asking for assistance. They experience unexpected light-headedness. They may even have a sudden heart attack, stroke, or seizure.
If you can’t stop all falls, you can reduce the risk of serious injury or death as a result of the fall.
One way to make this shift is to focus your attention on populations who are at particular risk for injury. You can use an “ABCs” mnemonic to remember these groups:
Age 85 and older, frail – for these people, a fall could be fatal. Falls are the number one cause of unintentional injury death in this age group.
Bones (brittle, at risk of fracture) – if people in this group fall, no matter what how they score on a fall risk screening, they could break a hip.
Coagulation (anticoagulant use or history of bleeding disorder – these patients are at higher risk of bleeding if they fall.
Surgery or other special procedure – this group can include younger patients who may misjudge when they’re ready to walk on their own.
Don’t Let Scores Drive Practice
We currently rely too much on a score to indicate a patient’s fall risk. We forget that the tools we’re using to get these scores are screening tools and not assessment tools. Assessments are comprehensive and multifactorial, and require an interdisciplinary team to complete. When relying solely on a screening tool to determine risk for falls, we may neglect to address the multitude of reasons a fall may occur and how to address them.
For example, consider a patient whose sight is impaired. If you can correct their vision, you can help them be safer when they get up and walk. If you treat a patient’s orthostatic hypotension, they won’t get dizzy after they stand up and fall as a result. In other words, scores alone should not drive practice. Identifying actual risk factors and treating them is the key to addressing modifiable fall risk factors, and implementing interventions to reduce risk of injuries that result from a fall.
Confronting the Inevitability of Some Falls
Health care providers have been trying to prevent falls for years with limited success. A number of factors — including an aging population and an increasing number of people having hip and knee surgery every year — will mean people are going to continue to be at risk of injuries from falls in our health care facilities. We have to reprioritize our limited time and resources to protect patients from serious fall-related injuries and loss of life.
We should put more effort into environmental safety rounds during which we assess patients’ surroundings with harm prevention as our lens. The goal is to address environmental hazards, such as sharp edges on furniture, metal shelves, and room accessories that could lead to someone losing an eye, getting a laceration, or breaking a bone in a fall.
Making injury reduction a priority doesn’t mean giving up on preventing falls. It does, however, mean we’ll need a different mindset. Fortunately, by instituting population-based injury prevention efforts tailored to individuals, our care will ultimately be more patient-centered, improve population health, and reduce costs.
And isn’t that the goal of the Triple Aim?
Pat Quigley is Associate Director of the VA Sunshine Healthcare Network (VISN 8) Patient Safety Center of Inquiry.
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