Patient Safety Tip of the Week

October 27, 2015

Sentinel Event Alert on Falls and View from Across the Pond



The Joint Commission (TJC) recently published its latest Sentinel Event Alert “Preventing falls and fall-related injuries in health care facilities” (The Joint Commission 2015). The new alert notes that every year hundreds of thousands (!!!) of patients fall in US hospitals and 30-50% of those falls result in injuries. Falls with serious injury have consistently been in The Joint Commission’s Top 10 sentinel events and 63% of those have resulted in death. The alert notes that a fall with injury adds 6.3 days and $14,000 cost on average to each hospital stay.


The most common contributing factors identified by TJC from sentinel event reports are:


So it’s no surprise that TJC recommendations focus heavily on addressing those common deficiencies. The alert identifies a variety of tools and resources that have been amassed on fall prevention (with links to those resources). The alert highly recommends use of a standardized assessment tool to identify fall and injury risk factors but also to assess an individual’s risks that may not have been captured through the tool. Interventions, then, should be tailored to the individual patient’s identified risks.


In our October 2015 What's New in the Patient Safety World column “Patient Perception of Fall Risk we noted the Joint Commission Center for Transforming Healthcare now has a Targeted Solutions Tool for Preventing Falls. The 7 hospitals participating in that project were able to reduce the rate of patient falls by 35 percent and the rate of patients injured in a fall by 62 percent. Extrapolated to a typical 200-bed hospital the number of patients injured by falls could be reduced from 117 to 45 annually and almost $1 million in cost reduction.


The sentinel event alert stresses the importance of leadership adopting fall prevention as a priority. It recommends having an executive sponsor for fall prevention programs, empowered to ensure accountability, build support, and ensure adequate people and fiscal resources for such programs. But it also stresses the importance of having a clinical champion who can influence stakeholders. An interdisciplinary falls prevention team is a key element in any successful fall prevention program and there needs to be a focus on communication issues, such as handoffs.


The alert then delves into a topic dear to our heart – what to do after a fall has occurred. That should include not only proper assessment of the patient but also a post-fall huddle held as soon as possible following the fall. At the latter the team should address why the patient fell, whether appropriate interventions were in place, how the care plan will change, and what can be done to prevent future similar occurrences. But it also stresses continued reassessment of the patient, looking for changes in the patient’s condition that might, for example, suggest a subdural hematoma (see our own prior columns on minor head trauma in anticoagulated patients listed at the end of today’s column).


For postfall assessment they provide links to two tools in the AHRQ Falls Toolkit: the “Postfall Assessment, Clinical Review” and the “Postfall Assessment for Root Cause Analysis”. The latter tool is one of the few we’ve seen that stresses the importance of checking orthostatic vital signs postfall. We’ve seen cases over and over where the history was strongly suggestive of orthostatic hypotension but no one ever bothered to check orthostatic signs at the most important time – right after the fall (see one of our typical rants on this in our April 16, 2007 Patient Safety Tip of the Week “Falls With Injury).


The sentinel event alert ends with links to great fall prevention resources from organizations like the AHRQ, IHI, ECRI Institute, ICSI, The Joint Commission Center for Transforming Healthcare, and the VA Center for Patient Safety.


At the same time a slightly different view on fall prevention comes from the UK. Much of the fall prevention recommendations for both clinical and organizational approach to falls come from two guidances from the National Institute for Health and Care Excellence (NICE 2013, NICE 2015). Results of an audit of hospital falls were recently released in the UK (Royal College of Physicians 2015). They often found a disparity between policies and practices. For example, only a fifth of patients were able to access their call bell and a third could not safely access their walking aid (if they used one). In addition, only 16% had their orthostatic vital signs assessed.


The UK takes an interesting approach to falls in the hospital. It has specifically recommends that hospitals cease using fall risk prediction tools! Instead they recommend that all adults aged 65 and older (and those aged 50-64 who are judged by a clinician to be at higher risk of falling because of an underlying condition) be considered at risk for falls. In our August 4, 2009 Patient Safety Tip of the Week “Faulty Fall Risk Assessments?” we discussed some of the ideas that went into the recommendation not to use fall risk prediction tools. Most notably, they argue that low scores may give you a false sense of security that a patient is not likely to fall. Such “scores” also tend to promote general fall prevention interventions rather than ones specifically tailored to the individual patient.


The UK also has a different (more liberal) approach to bed rails than we do on this side of the ocean (see our December 18, 2007 Patient Safety Tip of the Week “Bed Rails”). Because a systematic review of the scientific literature had indicated that falls from beds with bedrails “are usually associated with lower rates of injury” the UK recommendation has been that hospitals have policies on bedrail use and audit such use for appropriateness. The current audit showed all hospitals had policies but only half audited their use.


Recommendations made following the UK audit:


Each hospital should also have a falls steering group and a multidisciplinary falls working group that work in collaboration.


Another very interesting risk factor for falls, not routinely appearing on current fall risk assessment tools, was revealed at the recent ID Week 2015 conference. A study from the Massachusetts General Hospital (MGH) showed a surprising relationship between patients coming to the ER because of a fall and being diagnosed with an infection (Manian 2015). They reviewed 161 patients who had fallen and were subsequently diagnosed with an infection. The infection was not initially suspected in 41%. Most had none or only one of the usual signs of infection. For example, only about 20% had fever. Importantly, the morbidity and mortality associated with these patients was substantial. 18% suffered a fracture related to the fall (20% for those age 65 and older) compared to a national average of 2%. And 18% of those with infection died in hospital, compared with national rates of 3-5% for those over 65 admitted to a hospital because of a fall.


Several potential explanations for falls in those with infection were mentioned. The most obvious is that fever and perhaps anorexia might lead to dehydration and orthostatic hypotension. Another is that UTI’s (which accounted for 44% of the MGH series cases) may lead to the patient getting up at night, in the dark, to go to the bathroom, a scenario we know as common to falling (see our December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities”). Another possibility might be an infection leading to increased confusion in an older patient with dementia.


In that December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities” we noted that almost half of falls in the hospital occur during activities related in some way to toileting. Anticipating patients’ toileting needs is a critical component of successful hourly rounding programs (see our July 26, 2011 Patient Safety Tip of the Week “Hourly Rounding”). Assisting patients to the toilet late in the evening is particularly important. But 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.


While we concur that fall prevention strategies aimed at the entire hospital population have a role (eg. proper lighting, proper footwear, non-slip and non-trip surfaces, etc.), it is critical that fall risk factors are identified for each individual patient and interventions specific to those risk factors are implemented (see our August 4, 2009 Patient Safety Tip of the Week “Faulty Fall Risk Assessments?”).


Focus should be on potentially modifiable risk factors. But even some seemingly “non-modifiable” fall risk factors may still lead to specific interventions. For example, male gender has been identified in some tools as a risk factor for falls. While you obviously cannot modify that risk factor, you might look extra carefully at toileting needs of the male patient. We don’t know how much of the male risk for falls is “macho” vs. “modesty”. But if that latter is a factor in raising the fall risk during toileting in males, you may need to consider having non-female staff assist the males in toileting activities.


So we don’t think you should ignore non-modifiable risk factors but we think there are some good lessons learned here. While general patient safety efforts are important, focus especially on those things you can modify for the individual patient. So if you are using a fall risk prediction tool, don’t focus so much on the “score”. Rather focus on those specific items in the tool that are modifiable risk factors in individual patients regardless of the overall risk “score”.


Perhaps the most important take-home point from both the Joint Commission and the Royal College of Physicians publications is that policies and education/training are not enough. What’s important is that we make sure our actual practices are in keeping with those policies and best practices. Doing an audit periodically is a good way of assessing if we’re practicing what we preach.



Some of our prior columns related to falls:



Some of our previous columns on falls after correction of vision:


June 2010        Seeing Clearly a Common Sense Intervention

June 2014        New Glasses and Fall Risk

August 2014   Cataract Surgery and Falls



Some of our previous columns on head trauma in the anticoagulated patient:


April 16, 2007 “Falls With Injury

July 17, 2007  Falls in Patients on Coumadin or Heparin or Other Anticoagulants

June 5, 2012    Minor Head Trauma in the Anticoagulated Patient”.

July 8, 2014     Update: Minor Head Trauma in the Anticoagulated Patient







The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert. 55: 1-5 September 28, 2015



Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool for Preventing Falls.



AHRQ (Agency for Healthcare Research and Quality). Preventing Falls in Hospitals. A Toolkit for Improving Quality of Care. AHRQ (Rockville, MD) January 2013

“Postfall Assessment for Root Cause Analysis”

“Postfall Assessment, Clinical Review”



NICE (National Institute for Health and Care Excellence). Falls in older people: assessing risk and prevention. NICE guidelines [CG161] Published date: June 2013



NICE (National Institute for Health and Care Excellence). Falls in older people: assessment after a fall and preventing further falls. NICE quality standard [QS86]. Published date: March 2015



Royal College of Physicians (UK). The Falls and Fragility Fracture Audit Programme (FFFAP) 2015. National audit of inpatient falls. Audit report 2015



Manian FA, et al. IDWeek 2015 (Poster #813) as reported by Rosenthal M. Tripped Up by a Bug Instead of a Rug. IDSE (Infectious Disease Special Edition) 2015; 19: October 2015





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