Minnesota Hospital Association

Quality & Patient Safety

April 17, 2013

Minnesota Patient Safety Alert: Mitigating Fall Injury Risks

Background

Although Minnesota hospitals have been working diligently to eliminate falls and injury from falls, last year Minnesota had an increase in falls resulting in serious injury and fall deaths and there is a concerning trend that could lead to a higher number of deaths related to falls this year.

Review of the root cause information submitted in relation to these fall events indicate the following common factors:

  1. In 100% of fall death cases this year, the patients were at high-risk for injury from falls. In addition to having a system in place to identify and address an individual’s risk factors that put them at a higher risk for falls, MHA and MDH recommend facilities use the Fall Injury Reduction Protocol included in this alert as a guide to identify and mitigate modifiable risk factors that place patients at a higher risk of being injured if they do fall.
  2. In 67% of fall death cases this year, the patients were on anticoagulants and at risk for bleeding if a fall occurred. Interventions should be customized for patients with a coagulation risk factor that puts them at higher risk for injury, including the use of high/low beds, staying within arm’s reach, and educating patients and families about the increased risk of injury due to anticoagulation therapy.
  3. It was also noted that in 100% of the cases in which an alarm was in place, the alarm was ineffective in alerting the staff prior to the patient fall. Issues identified included:
    • Patient took alarm off
    • Alert not functioning properly
    • Alarms were not reactivated
    • Alarm not audible to nursing staff
    • Alarm did not provide sufficient lead time to prevent patient from getting up on their own.
MHA and MDH remind facilities that alarms alone are not a prevention strategy. If bed alarms are used, other redundancies need to be built in to the falls plan. Interventions should be customized to specific patient risks, including the use of high/low beds, floor mats, or staying within arm’s reach of patients when they are out of bed or the chair. If alarms are used, facilities should ensure they operate properly.
    MHA and MDH recommend that facilities revisit their fall and fall injury prevention policies and processes to address the issue of screening, assessing and linking appropriate interventions for patients with a coagulation fall injury risk factor. Recommendations your organization should consider in developing processes are reviewed in greater depth below.

    For more information on this alert, contact Julie Apold, MHA senior director of patient safety, at 651-641-1121 or toll-free at 800-462-5393; or Rachel Jokela, adverse health events program director, Division of Health Policy, MDH, 651-201-5807.

    Recommendations for Mitigating Fall Injury Risk for Patients on Coagulants

    These recommendations are intended to share best practices based on learnings from the adverse health event reporting system and statewide falls prevention activities involving Minnesota hospitals and ambulatory surgical centers. The recommendations are not intended to address all fall program related clinical and regulatory requirements.

    It is recommended that in addition to having a robust system in place to identify and address an individual patient’s risk factors that place them at a higher risk for falling (Appendix B), each organization should incorporate within this system a robust process for identifying and addressing each patient’s specific injury risk factors that place them at a higher risk for sustaining a serious injury if they do fall.

    A Fall Injury Reduction Protocol to identify and mitigate modifiable risk factors has been developed in consultation with the MHA Fall Advisory Work Group and Patricia Quigley, PhD, MPH, ARNP, FAAN, FAANP which provides a decision algorithm for identifying and mitigating specific fall injury risk factors (Appendix A). The algorithm is based on the ABCs fall injury risk factors:

    A = Age >85
    B = Bones
    C = Coagulation
    S = Surgical (post-surgical patients)

    Although any of these risk factors places the patient at greater risk for sustaining a serious injury from a fall, 67% of the deaths associated with an inpatient fall this current year have occurred in patients with a coagulation risk factor.

    It is critical that interventions are customized for those patients identified at risk of injury from a fall according to their specific risk factors.

    Interventions that should be considered for patients with a coagulation risk factor include:

    • Provide education to patients and families, which includes teach back, on why they are at a higher risk for serious injury if they do fall now that they are on blood thinners
    • High/low beds
    • Physical therapy consult to evaluate the patient’s mobility and patient’s physical environment for areas of injury risk
    • Include environmental checks within regular patient rounds, e.g., checking clutter, eliminating or padding sharp edges, floor mats are in place and are being used appropriately to pad flooring
    • “Staying within arm’s reach” (more information in Appendix C)
    • If the patient has a traumatic brain injury, consider a helmet
    • If the patient uses a wheelchair, place an anti-tipping device on chair
    • Alarms alone are not a prevention strategy: If bed alarms are used, other redundancies need to be built in to the falls plan, such as those outlined above. If an alarm is used, strategies need to be in place to ensure that the appropriate alarm is used for the patient, the alarm is operating properly, is activated and is set at the appropriate sensitivity and volume level.

    A sample flow diagram for conducting a patient fall screening, fall and injury risk assessment, and linking interventions for identified specific fall and injury risks is outlined in the link below. More detailed algorithms for specific fall and injury risk factors are included in Appendix A (Fall Risk) and Appendix B (Injury Risk).

    See Sample Flow Diagram, and Algorithms for specific fall and injury risk factors.