Patient Safety Tip of the Week
April 12, 2016 Falls from Hospital
Windows
The patient names
were different and the hospital names were different but the two cases were otherwise
almost identical. Last month a 43-year-old man died after falling from
the window of his sixth-floor hospital room at a Maine hospital. The patient
was recovering from a motorcycle accident earlier in the month in which he
suffered a traumatic brain injury. He apparently had been in a medically-induced
coma for a period but was recovering and getting ready for rehab. The patient’s
daughter believes her father was not suicidal, but was disoriented and trying
to get home to his family (Byrne
2016). “He wanted nothing
more in the world than to come home with the family, but with the extent of his
brain injuries he needed more hospital time and rehab before that could happen.”
“All he could focus on was getting home, and due to his state of mind he was
willing to try anything to get out of that hospital. He was able to open his
hospital window enough to get out,” she wrote.
This case sounds eerily similar to one we described in our
October 6, 2015 Patient Safety Tip of the Week “Suicide
and Other Violent Inpatient Deaths”. That case involved a 26-year old male
patient in Pennsylvania who had suffered a head injury in a motorcycle accident
(Darragh
2014a). He was said to have an “impulse control disorder” following the
head trauma and was on continuous observation by a hospital security guard in
an ICU when he entered the bathroom and locked the door. He then smashed
double-paned locked windows and jumped to his death from the sixth floor. The
guard had not received the same training that nurses who usually provide
continuous observation would have had. Such would have required continued observation
of the patient in the bathroom at least via a partially open door.
According to the Portland (Maine) Press Herald report (Byrne
2016), newly constructed
hospital facilities in Maine must meet the American Institute of Architects
2006 general guidelines for hospitals, which doesn’t require windows in patient
rooms to be openable. However, if windows in patient rooms are able to be
opened, “operation of such windows shall be restricted to inhibit possible
escape or suicide,” the standards state. Those new standards may not have
applied to the hospital section in which the patient in this case was housed.
Another critical factor we see over and over is that there
may be inadequate training for those
charged with close monitoring or observation of patients. This is
especially the case on med/surg floors when patients
are identified as being at high risk for suicide, other self-harm, or wandering
and elopement.
In the Pennsylvania case the patient had been hospitalized
and four times tried to leave the hospital against medical advice (Darragh
2014b). He was successful twice and was picked up by police and
returned to the hospital. Previous attempts at elopement are a risk factor for subsequent
elopements (see our July 28, 2009 Patient Safety Tip of the Week “Wandering,
Elopements, and Missing Patients”).
In patients committing suicide, we often see that a period
of greater vulnerability when their depression is improving. The same probably
applies to the patient with traumatic brain injury (TBI) and staff need to be
aware that the impulsivity often
seen after TBI accompanied by the desire to go home can lead to the sort of
disastrous consequences unfortunately seen in these two cases.
Most of you are familiar with patients having dementia or
Alzheimer’s disease who may be prone to wandering and elopement. But any
patient with impaired cognition may be at risk. This includes patients with
psychiatric disorders, developmental disabilities, and acquired neurological
disorders such as traumatic brain injury (TBI).
Some standardized questions that appear on most wandering
assessment tools are:
- Is there a history of
dementia?
- Is there a prior history
of wandering or elopement?
- Has the patient been
legally committed?
- Do they have a
court-appointed legal guardian?
- Are they a danger to self
or others?
- Do they lack cognitive
ability to make decisions?
- Do they have physical or
mental impairments that increase risk of harm?
- Do they walk round
aimlessly?
- Do they often get
agitated doing simple tasks?
- Do they ask the same
question over and over?
- Do they frequently ask
where they are?
A prior history of wandering or elopement (eg. at a long-term care facility prior to admission) should
be a red flag.
We’ve also often discussed that intrahospital
patient transports may also be vulnerable events. You’ve heard us talk on
several occasions about the “Ticket to
Ride” concept in which a formal checklist is completed for all transports (eg. to radiology). Such checklists typically contain
information related to adequacy of any oxygen supplies and medications needed
but should also include information about things like suicide risk and wandering/elopement
risk. These all need to be conveyed to the caregiver who may be accepting the
patient in the new area. Just as we’ve talked about cases where a patient may
attempt suicide in a bathroom in the radiology suite that is not
suicide-proofed, a patient at risk for wandering or elopement may wander off
easily while waiting in the radiology suite if not appropriately supervised.
Behavioral health units and staff are usually attuned to the
risk of patients eloping or attempting suicide. But these cases illustrate that
staff on med/surg units or ICU’s or rehab units also
need to be aware of risk factors for wandering, elopement, suicide or other
impulsive behavior. Doing risk assessments and ensuring that staff caring for
at-risk patients are adequately trained in dealing with such patients is
important. When high-risk patients are identified it is also important to
ensure they are not left alone in rooms with windows that can be opened (or
broken) by patients.
Some of our prior
columns on preventing hospital suicides:
- January 6, 2009 Patient
Safety Tip of the Week “Preventing
Inpatient Suicides”
- February 9, 2010 Patient
Safety Tip of the Week “More
on Preventing Inpatient Suicides”
- March 16, 2010 Patient Safety Tip of the Week “A
Patient Safety Scavenger Hunt”
- December 2010 What’s New
in the Patient Safety World column “Joint
Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
- September 27, 2011
Patient Safety Tip of the Week “The
Canadian Suicide Risk Assessment Guide”
- December 2011 What’s New
in the Patient Safety World column “Columbia
Suicide Severity Rating Scale”
- July 2012 “VA
Checklist Reduces Suicide Risk”
- August 2013 “Suicide
Attempts on Med/Surg Units”
- August 25, 2015 “Checklist
for Intrahospital Transport”
- October 6, 2015 “Suicide
and Other Violent Inpatient Deaths”
- March 2016 “TJC
Sentinel Event Alert on Preventing Suicide”
See our previous columns on wandering, eloping, and
missing patients:
- July 28, 2009 “Wandering,
Elopements, and Missing Patients”
- December 2012 “Just
Went to Have a Smoke”
- April 2, 2013 “Absconding
from Behavioral Health Services”
- October 15, 2013 “Missing
Patients”
- December 2013 “Lessons
from the SFGH Missing Patient Incident”
References:
Byrne M. Daughter: Fall victim at Maine Medical Center
wasn’t suicidal, was probably disoriented. Portland Press Herald 2016; March
31, 2016
Darragh T. State: St. Luke's staff
not properly trained to monitor man who jumped to death from hospital window.
The Morning Call (Allentown, PA) August 6, 2014
Darragh T. Death at Pa. facility
highlights security challenge for hospitals. The Morning Call (Allentown, Pa.)
June 21, 2014
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