Hospital Falls & Patient Safety Expert Article

In this article, Rehabilitation Expert, Christian Mongrain discusses patient falls in the health care setting. He covers the impact of falls, why they occur, and best demonstrated practices utilized by health care professionals to reduce the incidence and severity of fall incidents.

Falls in Hospitals and Other Health Care Settings

Falls are the most common adverse event reported in hospitals. According to the National Quality Measures Clearinghouse, falls are a leading cause of hospital-acquired injury, and frequently prolong or complicate hospital stays. Review of observational studies in acute care hospitals show that fall rates range from 1.3 to 8.9 falls/1,000 patient days. Falls occur at higher rates (8.9 to 17.1 falls/1,000 patient days) in units that focus on eldercare, neurology and rehabilitation. The Institute for Health Care Improvement has identified falls as the leading cause of death in people 65 and older, with 10% of fatal falls for the elderly occurring in hospitals.

Falls resulting in injuries in the health care setting are on the rise. Depending on the setting, as many as 15% of inpatients experience at least one fall, and The Joint Commission estimates that 30% of falls in health care settings result in serious injury. Most falls in health care settings are multifactorial and require investigation by an experienced expert to identify factors causing the fall, and to determine if standards of care were provided to prevent it.

How are Falls Defined in a Hospital Setting?

The National Quality Forum (NQF) defines a fall as an unplanned descent to the floor (or extension of the floor e.g., trash can or other equipment) with or without injury to the patient.

Why do people fall?

Risk factors associated with falls can be categorized as either Intrinsic or Extrinsic. Intrinsic factors include physiologic impairments that may be pre-existing due to a person’s past medical history, or new as they relate to the reason for admission. Extrinsic factors relate to the environment occupied.

To understand falls, one must first understand balance. Humans balance by taking input (received through vision, sensation, equilibrium, and proprioception), then processing it (in the brain), and then reacting via an output mechanism (such as moving one’s head, limbs, trunk, or eyes). When a person has a reduction in their ability to receive, process, or react appropriately to stimuli, they are more likely to lose their balance and fall.

Intrinsic/Physiologic Factors:

Several physiologic factors influence a person’s risk for falls. Often a disease process or side effect resulting from a surgery or injury may have significance. For example, an injury or illness may lead to a person having weakness in one or more extremities, a decrease or absence of sensation or proprioception, impaired or altered vision, or impaired safety awareness.

Patients may also experience side effects of medication, dehydration, or immobility that can increase their risk for falls. Orthostatic hypotension (a sudden drop in blood pressure when transitioning to an upright position) is not uncommon and should be monitored for by checking vital signs and symptoms as a patient progresses to standing.

Extrinsic/Environmental Factors:

Environmental factors influence risk for falls. These can include slippery or uneven surfaces, obstacles or tripping hazards, inappropriate lighting, elevated noise levels, limited access to assistive devices or assistive equipment, and hazards related to the height of the bed, toilet, chairs, or equipment.

There may also be opportunities for equipment failure due to inadequate inspection and maintenance, overloading, non-compliant pairing of equipment (mattresses to beds, slings to mechanical patient lifts, leg rests to wheelchairs, etc.), or misuse.

The availability of the care provider (nurse, nursing assistant, therapist, etc.) may also impact a person’s risk for fall. This may be influenced by the staffing ratios (care providers to patients), staff training, and guidelines for safe patient handling. Health care facilities are required to ensure that their staff are competent and capable of providing safe care, and to provide patients with appropriate methods to request assistance when needed.

Standard of Care for Fall Prevention in Health Care Facilities

Not every fall can be predicted or prevented. However, evidence-based practice has determined that use of risk assessments to identify which patients are at risk for falls and injury from falls, followed by implementation of measures to prevent falls can reduce patient risk of falls and injury. This may include one or more of the following techniques:

• Screening patients for fall risk and fall-related injury risk factors on admission (osteoporosis or blood clotting abnormalities)
• Creating a fall prevention and response team involving interdisciplinary health care workers
• Reviewing plan of care and standards as they relate to falls
• Communicating and educating staff and patients about patient fall risk and injury risks
• Clearly identifying patients at increased risk for falls
• Increasing the frequency and duration of patient observation and assistance to address needs such as mobilizing to the bathroom
• Completing assessments of the environment to identify and address fall hazards
• Modifying the environment and equipment including bed height and use of bed rails to reduce fall hazards
• Assessing patient’s mobility prior to allowing patients to freely leave their bed
• Training patients on the use of call lights and assistive devices like walkers, crutches, or wheelchairs
• Assigning interventions up to and including 1:1 companions for individuals with impaired safety awareness

Through the effective development of fall prevention policies and procedures it is possible for health care facilities to reduce the incidence and severity of fall events. The health care experts at Robson Forensic are frequently retained to investigate disputes involving the adequacy of patient care and supervision. 

Patient Falls Expert Witness Investigations

The experts at Robson Forensic are frequently retained to investigate the adequacy of care provided in hospitals, nursing homes and other health care facilities. Our experts can address many aspects of these cases from administrative policies and procedures, to the level of care provided by health care professionals, or the maintenance and custodial practices of care facilities.

For more information, submit an inquiry or call us at 800.813.6736.

Featured Experts

Christian H. Mongrain, PT, DPT, HEM

Doctor of Physical Therapy & Health Care Administration Expert

Dr. Mongrain is an expert in the continuum of care provided to patients in health care settings. He is experienced in creating and implementing injury prevention training for patients and employees,… read more.

Joseph Muniak, MS, OTD, OTR/L

Doctor of Occupational Therapy & Health Care Administration Expert

Dr. Muniak is a board-certified Occupational Therapist (OTR) and hospital administrator with expertise in the continuum of care provided to patients in the acute hospital, inpatient rehabilitation,… read more.