Patient Safety Tip
of the Week
July 10, 2018
Another Jump from a
Hospital Window
Jumps and/or falls
from hospital windows are rare events. Unfortunately, we do continue to see
fatalities due to such jumps/falls and there are several themes and patterns common
to such incidents. We’ve emphasized in several previous columns that there are
important lessons learned from prior incidents. We discussed many of these in
our Patient Safety Tips of the Week for April 12, 2016 “Falls
from Hospital Windows” and February
14, 2017 “Yet
More Jumps from Hospital Windows”.
Even though we lack details on many of these cases, there
clearly is a pattern. Moreover,
there are some surprisingly simple issues that are actually very good lessons
learned. The typical patient is a young or middle-aged male, but occasionally
elderly patients or females have also jumped through or out of windows. The
patient is often admitted for an attempted suicide but, again, not always.
Typically, he/she is confused or hallucinating. It’s not just patients with
known psychiatric disorders or a history of suicide attempt that are at risk.
Patients with brain injuries or delirium are at risk, particularly those who
have demonstrated a tendency to wander or have verbalized their intent to “get out of here” or “go home”.
And the incidents have commonly occurred while patients are already on 1:1
continuous observation and the observer is actually in
the room. Many such incidents occur when patients are housed on non-psychiatric
units or general medical floors. Hospital beds are often used as “launch pads”.
A recent fatal jump from a hospital window illustrates many
of these themes (Meehan
2018, WBAL
2018). The patient, a 47-year old man, apparently was on a “suicide watch”
but was housed on a 10th floor general medical unit because of a
high heart rate. He “refused to take his medicine and became aggressive.” He attempted
to strike a staff member with a computer, according to a police report. He
“then began to scoot his body closer to the end of the bed then [he] lunged
toward the window.” He broke the window with his elbow and jumped out the
opening, landing on the third-floor ledge of the hospital, according to police.
One obvious question always raised in such incidents is “why
don’t you have windows that are not easily broken?” The
hospital spokesperson in the above case said that the windows were within code
for that type of room. But most general acute care hospitals have not installed
the type of window used on
behavioral health units that is not
breakable or subject to manipulation. But perhaps it might be reasonable to
designate one or two rooms on acute care floors for housing such patients
deemed at risk and install such windows in those rooms. And, given that many
such victims have been head trauma patients, perhaps it would be wise to
install such windows on any acute head trauma units or other units dealing with
TBI patients. But be wary that even windows you may consider “safe” may not be.
At one hospital a male patient (no further details) removed a metal grill from
a third floor window and fell out (Malloy
2016). The hospital subsequently checked the “safety restrictors” on all
their windows.
So, what are the more subtle
lessons learned? First is that several patients were able to stand up on the
bed and “launch themselves” through the window from the bed. That implies a proximity of the bed to the window. In
our February 14, 2017 Patient Safety
Tip of the Week “Yet
More Jumps from Hospital Windows” we said one key lesson is to position the patient’s bed in the
room at a reasonable distance away from the window so such “launches” are not
possible. For example, if you have a high-risk patient in a typical double
patient room, it may make sense to remove one bed and move the remaining bed to
a more central position where it cannot be used to launch at the window.
Second, positioning
of the observer may be important. The observer is usually positioned in the
room on the side away from the window and near the door. We suspect that is
intentional and may be a consideration for the safety of the observer plus it
would allow the observer to easily yell for help if necessary. But that
obviously needs to be rethought.
And some other less obvious equipment needs to be removed.
That applies not only to the second bed but also to any object in the room that might be used to break the window, such as a
chair or piece of medical equipment. In another recent case, a 70-year old man with a history of mental
illness, drug and alcohol abuse, and was being evaluated when he picked up a
chair and smashed the window in an 8th floor hospital room and
jumped to his death (AP
2017, Valenzuela
2017). Care must be taken to
make sure such objects are not in reach for a patient even for a very brief
time. For example, if the observer needs to briefly leave the room perhaps their
chair should be removed. In the case above, the patient apparently attempted to
strike the observer with a computer.
But at a minimum, every room that is to be used for at-risk patients needs a thorough
environemental assessment such as the VA’s Mental
Health Environment of Care Checklist. Particularly in a room where medical
equipment is being used there will be special dangers. For example, in a case
discussed in our February 14, 2017 Patient
Safety Tip of the Week “Yet
More Jumps from Hospital Windows” the patient’s oxygen had been discontinued but the mask, tubing,
etc. were still in the room. These are objects that can be used by a patient to
hang himself or otherwise injure himself. So make sure that medical equipment and
supplies that are no longer needed are promptly removed from the room. The
environmental assessment should also evaluate the immediate surroundings. For
example, in that previous case there was a stairway
exit 15 feet from the patient’s room with a door that was unlocked. (Note that we’ve discussed the VA’s Mental
Health Environment of Care Checklist in several columns and will probably
do another soon. Recent studies (Watts
2016, Mills
2016) have shown that it has been very successful in reducing suicides,
perhaps more important than any other interventions.)
And one extremely important factor we’ve also discussed, not
only in preventing falls/jumps from windows but also in preventing hospital
suicides in general, is the importance of adequate
training for the personnel designated as observers. Most people assigned as
observers on med/surg floors have never worked in behavioral health units or
even worked with behavioral health patients. Often
they are not even healthcare personnel (some hospitals have utilized security
personnel as observers) and may not have been adequately trained to recognize
red flags or trained in de-escalation
techniques.
Staff on med/surg units, ICU’s and rehab units need to be
aware of risk factors for wandering, elopement, suicide or other impulsive
behavior just as much as staff on behavioral health units do. 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 and appropriate
environmental assessments done to minimize the chance a patient may harm
him/herself.
Lastly, don’t forget 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. We also hope that
you’ve checked those bathrooms in radiology for loopables
and other implements that might be used in a suicide attempt (see our March 16, 2010 Patient Safety Tip of
the Week “A
Patient Safety Scavenger Hunt”).
See also our December
12, 2017 Patient Safety Tip of the Week “Joint
Commission on Suicide Prevention” for the Joint Commission’s recommendations for suicide prevention in
general acute inpatient settings and emergency department settings.
So if we were doing the RCA (root cause
analysis) on the above case, here are some of the questions we’d be asking:
- Was housing of the patient on a general medical unit the most
appropriate location?
- Were the staff doing the observation appropriately trained to deal
with potentially violent or suicidal patients?
- Were they trained in de-escalation techniques?
- What actions were taken when the patient became aggressive?
- Why was the hospital bed positioned near a window?
- What unnecessary equipment was in the room?
- Were there other beds in the room?
- Were there other items in the room that could be used to break
windows?
- Could we have a room that had windows which are unbreakable or
cannot be tampered with?
- Have we done an environmental assessment, such as the VA’s Mental
Health Environment of Care Checklist, on the rooms we use that we use on non-psychiatric floors for patients
at risk for suicide?
- Are there nearby structures/spaces that could also be a suicide risk
(eg. bathroom,
stairwell)?
- Do we include provisions on our “Ticket to Ride” checklist for intrahospital transports to deal with patients at risk
for suicide or wandering?
Some of our prior
columns on preventing hospital suicides:
- January 6, 2009 “Preventing
Inpatient Suicides”
- February 9, 2010 “More
on Preventing Inpatient Suicides”
- March 16, 2010 “A
Patient Safety Scavenger Hunt”
- December 2010 “Joint
Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
- September 27, 2011 “The
Canadian Suicide Risk Assessment Guide”
- December 2011 “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”
- April 12, 2016 “Falls
from Hospital Windows”
- February 14, 2017 “Yet
More Jumps from Hospital Windows”
- August 29, 2017 “Suicide
in the Bathroom”
- December 12, 2017 “Joint
Commission on Suicide Prevention”
References:
Meehan S, McDaniels AK. State
investigating after man jumps from window to his death at Baltimore hospital. The
Baltimore Sun 2018; June 13, 2018
http://www.baltimoresun.com/health/bs-md-ci-ummc-patient-death-20180613-story.html
WBAL. Regulators Reviewing Death Of
Man Who Jumped From Baltimore Hospital Window. WBAL NewsRadio
2018; June 13, 2018
Valenzuela L. Elderly hospital patient smashes eighth-floor
window and jumps to his death. Fresno Bee 2017; August 22, 2017
http://www.fresnobee.com/news/local/article168798102.html
AP (Associated Press). Man, 70, leaps to his death from
eighth floor of Fresno hospital. LA Times 2017; August 23, 2017
http://www.latimes.com/local/lanow/la-me-ln-fatal-jump-20170823-story.html
Malloy T. Patient falls from window at Weston General
Hospital after removing safety grill. SomersetLive
2016; August 12, 2016
VA Mental Health Environment of Care Checklist (MHEOCC).
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained
Effectiveness of the Mental Health Environment of Care Checklist to Decrease
Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print:
November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care
Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in
Patient Safety) 2016; 16(3): 3-4
July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
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