Never Event #1: Hospital Falls & Trauma

Falls in trauma top the list of preventable medical conditions in hospitals, accounting for 193,566 incidents in 2007.  Falls in hospitals (and similarly in nursing homes) are deemed to be preventable by Medicare because with proper fall/risk assessments and staff assistance most falls in hospital could be avoided.  A number of factors should be addressed by a hospital to determine if a person is at risk for falls:

  • Medication that may effect balance or coordination
  • Does the person normally use an assistive device like a walker or cane?  If so, one should be provided by the facility at all times.
  • Age.  Older residents have a far greater risk of falling than their younger counterparts
  • Is the person able to use the bathroom themselves?  If not, regular assistance should be provided by the staff.

In a recent study by researchers at Washington University in St. Louis, patients were injured in 42% of falls occurring in the hospital.  Hospital patients were seriously injured in 8% of the falls with head trauma or fractures.  The study also determined that the people most likely to sustain a serious fall-related injury were those on their way to or in the bathroom.  iStock_000001025084XSmall

In addition to determining patients who are at high risk for falling, hospitals should take precautions to minimize the likelihood of falls due to sloppiness or inadequate staffing.  In order to assure resident falls are minimized hospitals should make sure the following in done:

  • Remove clutter from floor.
  • Remove improperly fitting slippers and other clothing.
  • Keep bed rails up when patients are sleeping.
  • Provide adequate staff and equipment when transferring into and out of bed.
  • Install handrails in areas where patients need stability.
  • Keep call lights within reach of residents in bed at all times.  Residents can request assistance easily.
  • Lock wheels on wheelchairs and beds when transferring patients.

If a fall occurred during a hospitalization, do not assume that the fall resulted from an unforeseeable condition.  There is a good likelihood that the hospital should of identified the patients likelihood of falling and taken precautions.

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