Patient Safety Tip of the Week


December 22, 2009             Falls on Toileting Activities




Almost half of falls in the hospital occur during activities related in some way to toileting (see our January 1, 2008 Patient Safety Tip of the Week “Fall Prevention” and our October 7, 2008 Patient Safety Tip of the Week “Lessons from Falls....from Rehab Medicine”). Despite this fact, surprisingly little research has been done on this phenomenon.


Now a new study (Tzeng 2010) focused on falls related to toileting. Tzeng did a literature review on this topic and an analysis of 547 falls that took place on medical, surgical or mixed medical/surgical units in a community hospital. Toileting activities included not just those that occurred in the bathroom but any in which the intent to toilet was present prior to the fall. 45.2% of the falls in the Tzeng study occurred on activities related to toileting. Only 6% of the falls actually occurred while getting on or off the toilet but most of the falls occurred when attempting to go from bed or chair to the bathroom or returning from the bathroom.


Interestingly, the maximum time period for falls in the Tzeng study was between 11 PM and 3 AM and over 60% of the falls occurred between 7 PM and 7 AM. That is different from the daytime preponderance of falls noted in rehab medicine patients. So you really need to analyze the falls data at your own facility to see what time of day your patients are most likely to fall. A study of falls in a multiple hospital system (Krauss 2007) showed that there are differences in risk factors for both falls and serious injury based on the type of hospital. Another study from the same group (Fischer et al 2005) showed substantial differences in fall rates and rate of fall-related injuries by type of service the patient was on. However, the Tzeng study was from a general community hospital so the times of falling are likely representative of many hospitals. In addition to the staffing issues noted below, the timing of falls has implications for lighting in patient rooms. Tzeng recommends use of night lights or motion-sensor lights in or near patient bathrooms.


But here is the most bothersome finding in the Tzeng study: almost all the falls occurred in patients who had already been classified as high risk for falls and were on fall risk precautions. Tzeng makes a case for better auditing and surveillance of our fall prevention programs. It is simply not good enough to identify patients as being high risk for falls if our interventions are inadequate or, worse yet, ignored. Particularly when nursing is understaffed or otherwise overworked, there is a tendency to skip some of the pre-emptive activities to help avoid patients falling when getting out of bed at night. A previous study (Krauss et al 2008) showed poor staff compliance with toileting schedules, even during a period of a targeted intervention. Given that the period of greatest risk for falls in the Tzeng study was between 11 PM and 3 AM, it is worth remembering the point of last week’s Tip of the Week “The Weekend Effect” in which we noted all the other nonclinical things nurses get stuck doing after-hours. These clearly take away from bedside nursing activities. Perhaps the toileting needs of our patients are better met by aides or staff other than nursing. Perhaps a specially-trained aide or team could work from 10 PM to midnight or 9 PM to 11 PM and just focus on ensuring all patients at high risk for falls get appropriate assistance toileting before they go to sleep. Keep in mind that such attention to toileting is also important in the patient at risk for delirium. Note that we have also mentioned the gender issue on several occasions. Many studies have identified male sex as a risk factor for falls. We don’t know if that is due to macho vs. modesty. If it is the latter, then male patients may be hesitant to ask a female nurse to help them to the bathroom. So consider having some male aides on your “team” to assist male patients with toileting as well.


The Krauss paper (Krauss et al 2008) also had another lesson not unfamiliar to those involved in performance improvement projects: many good projects are not sustainable. In that study, a focused intervention to prevent falls was quite successful over the first 5 months but by 9 months the results were no longer statistically better compared to the control group.

Tzeng stresses something we have frequently noted is sorely lacking: good analysis of after a fall has occurred. The typical medical responder after a patient fall does a good job looking to see if the patient was injured but seldom does a good analysis as to why the patient fell. We recommend you do an on-the-spot fall investigation for every fall. That is the only way you are likely to identify the specific fall risk factors for that patient. We have discussed previously that most of the general fall risk assessment tools simply identify patients as being at risk for falls (and still miss a significant number who will fall) but do not lead to interventions that would address specific risk factors in the individual patient (see our August 4, 2009 Patient Safety Tip of the Week “Faulty Fall Risk Assessments?”).


Though not yet directly related to falls, another interesting paper appeared last week (Kraft et al. 2009) on “lying obliquely”. They found that patients who lie obliquely in bed (i.e. at an angle to the longitudinal axis of the bed rather than aligned straight with that axis) have a substantial likelihood of cognitive impairment. Lying obliquely is really a sign of visuospatial impairment. One might expect that this clinical sign might be a good predictor of falls as well. In fact, this very sign has been described long ago in patients prone to falling (Tobis et al 1981). So don’t be surprised in about 2 years when the “lying oblique” sign pops up on your fall risk assessment!


To summarize the lessons from these papers:

  • Toileting activities are a significant risk factor for falls in all hospitals
  • Such falls are more likely to occur at night
  • Fall-prevention interventions related to toileting activities are poorly complied with
  • Consider teams of staff other than nurses to address the toileting interventions
  • Audit compliance with all your fall-prevention strategies






Tzeng H-M. Understanding the Prevalence of Inpatient Falls Associated With Toileting in Adult Acute Care Settings. Journal of Nursing Care Quality 2010; 25(1):22-30



Krauss MJ, Nguyen SL, Dunagan WC, et al. Circumstances of Patient Falls and Injuries In 9 Hospitals In a Midwestern Healthcare System. Infection Control and Hospital Epidemiology 2007; 28: 544–550



Fischer ID, Krauss MJ, Dunagan WC, et al. Patterns and Predictors of Inpatient Falls and Fall-Related Injuries in a Large Academic Hospital. Infection Control and Hospital Epidemiology 2005; 26: 822–827



Krauss MJ, Tutlam M, Costantinou E, et al. Intervention to Prevent Falls on the Medical Service in a Teaching Hospital. Infection Control and Hospital Epidemiology. Volume 29, Issue 6, Page 539–545, Jun 2008



Kraft P, Gadeholt O, Wieser MJ, Jennings J, Classen J. Lying obliquely—a clinical sign of cognitive impairment: cross sectional observational study. BMJ 2009; 339: b5273 (Published 16 December 2009)



Tobis JS, Nayak L, Hoehler F. TitleVisual perception of verticality and horizontality among elderly fallers. Archives of Physical Medicine & Rehabilitation 1981. 62(12):619-22










Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive