Preventing Patient Safety Dilemma of Falls

Let the Bodies Hit the Floor: A Patient Safety Dilemma

The Agency for Healthcare Research & Quality describes a fall as an unplanned descent to the floor that may or may not result in an injury to the patient (AHRQ, 2019).  The facility where I am currently employed has had a recent safety issue because our number of falls has increased dramatically on the Inpatient Rehabilitation Unit.  As an organization we strive to provide the best possible care in our area and preventing falls is a part of that care.  We currently have interventions in place to prevent falls such as a fall bundle that includes non-skid socks, fall bracelet, and bed/chair fall alarms.  The purpose of this paper is to evaluate the root cause of falls on the inpatient rehabilitation unit at EAMC-Lanier along with research for proposed interventions and reinstatement of current fall policies.

The patient population that is admitted to an inpatient rehabilitation unit are patients that require an aggressive therapy program that can include at least two scheduled therapies such as speech therapy, occupational therapy, or physical therapy for a total of three therapy hours.  These particular patients are at an increased risk for falling as they may be admitted for debility, hip fracture, major trauma, cerebrovascular accident, traumatic brain injury, or exacerbation of a chronic illness that may affect the patient’s ability to perform daily activities safely.  As a unit we encourage as much mobility and independence as safely possible; So, our patients are getting up to go to the restroom instead of using the bedpan, taking showers instead of bed baths, eating breakfast, lunch, and dinner in the dining room;  they are also dressed in their clothes from home rather than wearing a hospital gown and their stay is anywhere from seven to 21 days, sometimes longer.

Joint commission has listed falls with or without injury as a sentinel event.  Studies report that three percent of hospitalized patients fall and 25 % of those have a fall with injury (Dykes, Adelman, Adkison, Bogaisky, Carroll, & Carter, 2018).  A fall with injury could include a fall that results with bruising, bone fractures, or subdural hematoma (Dykes, et al, 2018).  In an effort to reduce falls the Quality and Safety Manager from our sister hospital hosted a round table meeting to evaluate our current fall prevention procedures.  I am the charge nurse for this unit, so I was included in this meeting along with the primary nurse, care assistant, pharmacist, all participating therapists with specific patient, and the hospitalist.  It was determined that we were not following our current fall prevention program appropriately and we also decided to incorporate some new ideas to add to our current fall prevention procedure.  Our staff were not applying the prevention strategies we had in place and night shift was not participating at all in fall prevention.  Therapy staff were also not being consistent in continuing the unit’s current fall prevention strategies.  The fall prevention items we have in place with our current fall rate of six for the month of August and six for the month of September are yellow fall bracelets for patients that are high fall risk, non-slip socks for each patient when out of the bed, chair and bed alarms for each patient.

The procedure for after a fall occurs is to perform a post-fall huddle.  The post-fall huddle includes the patient’s name, diagnosis, current medications that can affect the patient’s ability to safely ambulate or could cause emergent need to get to the restroom; it also includes if the patient has fallen previously during the current stay, was this fall on day of discharge, did an injury occur, what measures were taken after the fall, and who was contacted to notify of the fall.

LET THE BODIES HIT THE FLOOR                 4

There is also a place on the post-fall huddle for fall prevention interventions in place at the time of fall and measures taken after the fall to rectify any interventions not in place.  As an

organization we are to place a fall mat beside the bed to be used as a cushion if another fall were to occur.  Our unit also participates in performing fall safety rounds at spontaneous times to ensure proper use of fall prevention interventions.

Every month there is a meeting with the Quality and Safety Manager to evaluate all falls organization-wide to discuss with the post-fall huddles what interventions were and were not in place.  In a previous meeting a unit manager suggested that we use a calendar to mark the exact days of falls and what intervention was not in place to give a better visualization of the procedures, time of day, staff to patient ratio, and patient census.  For August and September 2019, 91% of falls did not have activated fall alarms, 75% of falls were unwitnessed, 67% of falls were with confused patients, 58% occurred in the patient’s room, 42% of the falls were between 0800-1130, and 24% were assisted falls (EAMC-Lanier Falls Review Team, 2019).

While thinking of this topic and all of the interventions we, as a facility have in place, I just could not figure out why our fall rate increased.  It turns out that we can have policy after policy, but it does not matter if our staff does not buy in to the culture of safety that was implemented.  A recent fall that occurred had a severe injury and the children of the patient were very upset and threatening a lawsuit; I believe that this particular fall with injury was motivation to encourage employees to participate in our patient safety program.

Interventions that we plan to put into place within the coming months are to have one ceiling tile in each room over the bed painted with bright colors that say “CALL DON’T FALL” to encourage patients to use the call light and ask for assistance before trying to ambulate by

themselves; We will place a fall alarm box on the bed, the recliner, and the wheelchair to decrease the chance of an employee forgetting to plug the fall alarm pad into the transferring

place such as going from the bed to the recliner; Ensuring there is a gait belt appropriately fitting for the patient readily available in each room;  Utilizing the call light function on the patient beds as sometimes the patients will verbalize they have been pressing the call light when no staff had

been alerted, it is possible they were pressing the red button on the side rails that are not actively working; Patients will be followed with a wheelchair by another employee when ambulating to be assisted to the chair instead of the floor if their legs happen to get weak while walking; Applying non-slip contact padding in between each layered item in the wheelchair such as non-slip padding > fall pad > non-slip padding > static air waffle cushion > non-slip padding > absorbent pad. An idea that is still being considered would be an accountability process that includes sending an email to all staff on the unit where the fall occurs that describes the patient’s perspective of the events of the fall and the events surrounding the fall along with the primary nurses’ point of view of the events surrounding and of the fall; this idea was performed on an acute facility unit where falls decreased by 55% (Hoke & Guarracino, 2016).

A study performed in France that used painted ceiling tiles in a dementia unit to enhance the feeling of day or night in certain rooms did not decrease the incidence of falls (Bautrant, Grino, Peloso, Schiettecatte, Planelles, Oliver, & Franqui, 2019);  Research is showing that an increased use of bed alarms does not decrease the incidence of falls when using bed/chair alarms (Shorr, Chandler, Mion, Waters, Liu, Daniels, Kessler, & Miller, 2012).

The goal set by EAMC-Lanier is to have no more than 3 falls in a month after all new fall prevention interventions are in place.  The current fall rate has been zero in the past 39 days with only the improved intervention of all staff members from day shift, night shift, and therapists

participate in performing fall safety rounds and having fall alarm boxes on each bed, recliner, and wheelchair.  The method that we will use to measure our outcome is the same method we currently use which is calculating the information from the unit calendar broken down daily along with the total number of patients on the unit each day.  A follow up evaluation will be performed to report to administration how our new interventions have proven to be successful or unsuccessful three months post new intervention initiation.  As an organization we will continue to have round table meetings on falls that incur injury to assess what we can improve along with if the fall rate maintains a rate of five or more falls in a month.


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    20(3), pp. 377-381.  doi:
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    116(1), pp. 42-47. doi: 10.1097/01.NAJ.0000476167.43671.00
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    157(10), pp. 692-699. doi:10.7326/0003-4819-157-10-201211200-00005