Abstract
Falls are common during hospitalization and associated with adverse outcomes including fractures, head injury, and even death. In the past decade, fall prevention has become a significant patient safety concern. In 2005, the Joint Commission included fall prevention as a National Patient Safety Goal and in 2008 the Centers for Medicare and Medicaid Services (CMS) identified falls with injury as a “never” event. Numerous fall risk assessment tools have been developed; however, few have been validated in more than one population. Single and multicomponent interventions have been tested in an effort to identify methods to reduce falls during hospitalization. However, the data regarding successful hospital fall prevention programs are sparse. The majority of these programs utilize bedside interventions such as frequent rounding, bed alarms, or low beds. While some of the individual studies have been successful, systematic reviews and meta-analysis have been less positive. One potential problem may be these interventions are not enough to reduce falls when tested in hospital systems that do not provide a culture of patient safety. Addressing larger system-wide concerns like improving handoffs and communication or improving knowledge and skills related to fall risk and prevention may be the key to reducing hospital falls. Root cause analysis (RCA) has been used extensively in hospitals to address falls in a systematic fashion with a goal of identifying and correcting the root cause to reduce reoccurrence. However, for patient safety problems like falls, that are high-volume and high-risk, aggregate RCA may be more appropriate. The aggregate RCA tool supports process and systems improvement by identifying trends and system issues across groupings of similar events. In the future, fall prevention strategies will need to address these system issues in order to be successful.
“As with dying, we recognize erring is something that happens to everyone, without feeling that it is either plausible or desirable that it will happen to us.”
Katherine Schulz
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Brown, C.J., Miltner, R.S. (2014). Hospital Falls. In: Agrawal, A. (eds) Patient Safety. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-7419-7_13
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DOI: https://doi.org/10.1007/978-1-4614-7419-7_13
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