2. Quality in Health
Prevention of patient falls e A case study
Gaurav Loria a,b,
*, Ankita Bhargava c
a
Coordinator Quality, Apollo Group, Jubilee Hills, Hyderabad, India
b
National Head Quality, Jubilee Hills, Hyderabad, India
c
Executive Quality, Apollo Hospitals, Hyderabad, India
a r t i c l e i n f o
Article history:
Received 23 January 2013
Accepted 18 February 2013
Available online 28 February 2013
Keywords
Patient safety
Precautions
Morse fall risk scale
Root cause analysis
a b s t r a c t
Fall-related injuries can be some of the most common, disabling, and expensive health
conditions encountered by adults, especially older adults. According to researcher Janice
Morse, approximately 14% of all falls in hospitals are accidental, another 8% are unantic-
ipated and 78% are anticipated falls. Guideline to prevent falls in the hospital has helped to
bring down the numbers and improve patient safety.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Patient falls: introduction
Patient falls have been identified by the Joint Commission as
one of the top five sentinel events for home care organizations
in its December 2003 sentinel event report.1
According to the
researcher Janice Morse, approximately 14% of all falls in
hospitals are accidental, another 8% are unanticipated and
78% are anticipated falls.2
Fall-related injuries can be some of the most common,
disabling, and expensive health conditions encountered by
adults, especially older adults.
The number of persons above the age of 60 years is fast
growing, especially in India. India as the second most popu-
lous country in the world has 76.6 million people at or over the
age of 60, constituting above 7.7% of total population. The
problems faced by this segment of the population are
numerous owing to the social and cultural changes that are
taking place within the Indian society.3
Every year thousands of cases of patient falls are reported
which majorly comprise of the elderly.
Main reasons for falls:
Lack of staff communication, orientation and training
No proper patient’s assessment
Physical environment
Care planning
Organization culture
Vulnerable patients are mainly those who are more
susceptible to a fall when admitted in a hospital like
patients above 65 years old (geriatrics), children less than
16 years of age (pediatrics), patients who are physically/
mentally challenged or patients who cannot perform acts of
daily living.
For effective management of such patients, five balancing
steps are required. These are:
* Corresponding author. Coordinator Quality, Apollo Group, Jubilee Hills, Hyderabad, India.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
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0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2013.02.006
3. 1. Determine the vulnerability of the patient and identify them
2. Patient First program or a special program to be
implemented
3. Frequent assessments and reassessments
4. Specific therapy
5. Supportive care
Team composition: Quality Systems and Nursing in
charges.
2. Objectives of study
To study the trend of patient falls in the hospital
To trace the causes of falls
To make necessary interventions to reduce the fall rate
To improve patient safety by introducing practices to pre-
vent falls
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4. 3. The process flow/guideline for fall
prevention
Fall and fall-related injury outcome measures
4. Assessment parameters
1. Number of patient falls per month
2. Patient fall rate
3. Percentage of patients who were classified under ‘low risk’
but had a fall
Key tasks: Modified Morse fall Risk Assessment was
made a part of the admission record. A separate sheet was
also designed and circulated in all Outpatient and Day
Care Areas to ensure the assessments of the patients.
Training of the nursing team was done by the Quality
Team.
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5. Interventions annexure4
Interventions High Moderate Low
Patient
education
- Orient patient to surroundings and hospital routines
- Orient patient about the call bells and make sure patient
is able to use it
- Instruct patient to call for help before getting out of bed.
- Instruct the patient and family about the significance of
fall prevention program
- Teach patient to use grab bars
- Discuss toileting needs of the patient and implement
bowel and bladder program if necessary
- Instruct the patient on side effects of drugs
- Orient patient to surroundings and hospital routines
- Orient patient about the call bells and make sure patient
is able to use it
- Instruct patient to call for help before getting out of bed
- Instruct the patient and family about the significance of
fall prevention program
- Teach patient to use grab bars
- Orient patient to surroundings and hospital routines
- Orient patient about the call bells and make sure patient
is able to use it
Nursing Place Patient First Card bed side
Side Rails Always Up
Lock all moveable
Equipment before transferring
Provide adequate lighting
Place Bed Pan/urinal within easy reach
Position the bed at low level with brakes locked/position
the foot stool in place
Communication Board Placement
Place assist devices within reach
Develop a schedule for turning and positioning
Increase frequency of patient rounds
Instruct housekeeping supervisor to keep pathway clear
from obstacles and keep toilet floor dry
Consider obtaining doctors order for physiotherapy
consult
Place Patient First Card bed side
Lock all moveable equipment before transferring
Provide adequate lighting
Place Bed Pan/urinal within easy reach
Position the bed at low level with brakes locked/position
the foot stool in place
Place Patient First Card bed side
Side Rails Always UP
Lock all moveable equipment before transferring
Provide adequate lighting
Documentation Vital signs recording as per orders
Assess patient’s condition in his ability to do acts of daily
living (ADL)
Physical restraints ordered
Physical therapy as ordered
Document the falls in incident report form and inform
Medical Head
Vital signs recording as per orders
Assess patient’s condition in his ability to do acts of daily
living (ADL)
Physical restraints ordered
Physical therapy as ordered
Document the falls in incident report form and inform
Medical Head
Vital signs recording as per orders
Assess patient’s condition in his ability to do acts of daily
living (ADL)
Physical restraints ordered
Physical therapy as ordered
Document the falls in incident report form and inform
Medical Head
Medication Minimize the use of medications that alter mental status.
Use alternatives to sleeping medications
Dispense diuretics before afternoon/evening
Treat pain
Screen and treat for hypoxia
Assess the clinical status of delirious patients to rule out
reversible etiologies
Promote mobility and fitness
Minimize the use of medications that alter mental status.
Use alternatives to sleeping medications
Dispense diuretics before afternoon/evening
Minimize the use of medications that alter mental status.
Use alternatives to sleeping medications
Dispense diuretics before afternoon/evening
Reassessments Every hour Frequent Every day
apollomedicine10(2013)175e180178
6. 5. The falls project
The project was implemented as a pilot for a week wherein
few departments were covered. The success in the pilot
project helped us to implement the same initiative all across
the hospital.
Data collection: The patient fall-related incidents
were reported to the Quality Team by Incident Forms.
These forms were the source of information of the falls
which were further analyzed through Root Cause Analysis
(RCA).
Sustainability initiatives: The completion of the form was
also checked through the Wake Up Call Rounds and reported
to the Nursing Heads. Continuous surveys and surprise checks
for documentation compliance and equipment safety were
carried out to ensure safety.
Patient and Family Education (PFE) was an integral part of
the whole process. Handbooks were introduced which helped
in explaining the patients and attendants better.
Improvement: Before taking up the project, our patient
falls were about 7 in the first six months (JaneJun 2011).
With vigorous training of the staff the incidents reporting
also improved and the number of falls reported was high
in the next six months (JulyeDec 2011). The following
six months (JaneJun 2012) the numbers came down dras-
tically which was a result of PFE and vigorous staff
training.
Findings/Results:
Findings JanuaryeJune 2011 JulyeDecember 2011 JanuaryeJune 2012
Number of falls 7 14 4
Reasons Patient fell in bathroom
(no assistance)
Patient ambulating to bathroom
Patient fell from bed
Patient’s physiological condition
Broken chair
Patient fell in bathroom (wet floor)
Patient fell in the bathroom
(no assistance)
Patient slipped in the room
Patient’s physiological condition
Patient’s physiological
condition
Patient fell from the bed
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7. The number of patient falls per 1000 discharges were found
to be well within the benchmarked limits.
It was also found that of all the patients who had a fall
21% were already categorized by the nursing staff as one
vulnerable to fall while 42% at a moderate risk and 37% at a
low risk.
The major reasons for fall were also analyzed after
completing a detailed review of every fall. The major reasons
ranged from patient’s fall from the bed to his physiological
condition to a fall in the bathroom at night.
It was also observed that maximum patient falls happened
at night (between 1 am and 4 am) when patients try to go
unassisted to the toilet without informing anyone (even the
attendant).
6. Conclusion
The implementation of the guideline has brought some
important outcomes.
The number of falls have been varying from 0 falls to 5 falls
per month. The staff has been trained on prevention and
management of falls. The Patient and Family Education has
been stressed upon with the bilingual patient education
booklets and flip charts.
Patient falls have happened due to various reasons of which
patientfallsinthebathroomandphysiologicalconditionofthe
patient have been the major causes. These have been taken
seriously and brought to the notice of the patient caregivers.
Adequate assessment of the fall risk has been stressed upon
to reduce the risk and training is being given to ensure fall
prevention.
To reduce such patient falls, patients as well as attendants
are being educated using flip charts.
We have also conducted training programs and competency
assessments for the entire staff of the hospital.
Conflicts of interest
All authors have none to declare.
r e f e r e n c e s
1. Reducing the Risk on Falls in Your Health Care Organization.
Joint Commission Resources http://www.patientsafety.gov/
SafetyTopics/fallstoolkit/index.html.
2. Preventing Patient Falls e Establishing a Fall Intervention
Program (2nd ed.) Janice M. Morse.
3. Falls in older people. National/regional review India. Dr. B.
Krishnaswamy, Professor and Head; Dr. Gnanasambandam
Usha, Assistant Professor, Department of Geriatric Medicine,
Madras Medical College and Government General Hospital,
Chennai City, Tamil Nadu State, India.
4. http://www.downstate.edu/patientsafety/falls.html.
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