Preventing patient falls in perioperative settings
AORN Journal
February 2005
by Suzanne C. Beyea
As part of the 2005 National Patient Safety Goals, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires hospitals and critical-access hospitals to assess and periodically reassess each patient's risk for falling. (1) This includes identifying risks related to each patient's medication regimen and taking action to address any identified risks. This goal addresses JCAHO's concern that fatal falls account for 4.6% of the sentinel events reviewed by the Joint Commission from 1995 to the end of 2003. Although many nurses working in perioperative settings believe that patient falls are a problem in inpatient units, falls can and do occur in perioperative settings. (1)
More than a decade ago, I heard a story about a patient fall in the OR. An individual observing a surgical procedure reported that after the surgical repair of the patient's fractured hip was completed, surgical team members were busy cleaning up the room and had their backs turned when the patient rolled off the table. The observer noted that the patient had seemed too big for the table and simply had rolled off. Fortunately, the patient experienced only minor injuries, although there were concerns about re-injury to the repaired hip as well as potential new injuries. As a result, additional diagnostic testing was performed on this patient, and it ruled out injuries requiring additional treatment or intervention.
When I share this story with other perioperative nurses, they usually can relate their own stories of a near-miss or an actual patient fall. Perioperative patient falls can occur in the preoperative or postoperative phase of care in both ambulatory and hospital settings, as well as in the OR. Falls in the OR may occur during transfer of the patient onto or off of a stretcher or during the provision of care. The low incidence of falls in perioperative settings reported makes it somewhat difficult to specify interventions that will prevent falls in these clinical situations, but JCAHO provides some general guidelines.
JCAHO's RECOMMENDATIONS
In the 2005 National Patient Safety Goals, JCAHO recommends that organizations complete an assessment and reassessment of fall risks. (1) The Joint Commission recommends that an initial assessment include an individual's
* history of falls,
* overall cognitive level,
* impaired mobility or balance,
* muscle strength,
* chronic diseases,
* nutritional problems,
* pain level,
* ability to perform activities of daily living, and
* use of multiple medications.
Further, JCAHO suggests that general risk reduction strategies include
* installing bed alarms;
* installing self-latching locks on utility rooms;
* restricting window openings;
* installing alarms on exits;
* providing fall prevention education to patients and their family members;
* improving and standardizing nurse call systems;
* using low beds for those at risk for falls;
* revising staffing procedures;
* counseling individual caregivers; and
* creating a falls prevention committee to examine fall risk potential, evaluate interventions, examine trends and patterns, and communicate with other staff members. (2)
Perioperative nurses reviewing this goal and its suggested strategies might question its applicability in perioperative settings. In fact, many of these recommendations appear to be more applicable to inpatient departments or long-term care facilities.
FALLS IN THE OR
Little is known or understood about the incidence or nature of near-misses or actual falls in perioperative settings. Many nurses may have anecdotal stories about falls, and health care organization staff members may have knowledge about the nature and type of falls that have occurred in perioperative settings, but no national database exists to provide guidance for understanding risks or appropriate interventions.
To help prevent surgical patient falls, perioperative nurses must work together to identify and understand risks and propose interventions that will reduce these risks. Until adequate data are collected and research is conducted, expertise derived from research conducted in other clinical settings must be used to guide practice. Additionally, data from case reports and other sources must be collected and analyzed to more clearly define risk states and prevention strategies for perioperative falls.
WHO IS AT RISK?
Perioperative nurses must determine who is at risk for falls in perioperative settings. Certain conditions place all patients at higher risk for falling, including
* history of a fall during the past three months,
* use of certain medications,
* confusion,
* depression,
* altered elimination,
* dizziness, and
* male gender. (3)
When completing a nursing assessment, perioperative nurses should determine whether any of these risk states exist. Nurses in perioperative settings also need to consider that patients undergoing surgery experience an increased risk of falling due to preoperative medications; anesthetic agents; a lack of familiarity with the environment where care is provided; and sensory-perceptual deficits, including the removal of hearing aids and glasses. These factors, compounded by potentially slick floors, a lack of slip-proof footwear, and the use of elevated stretchers and beds, present additional risks for falling. Perhaps nurses need to identify all surgical patients at risk for falling and further define a sub-group of patients who are at the greatest risk of falling.
APPROPRIATE INTERVENTIONS
What are the appropriate interventions for preventing falls in perioperative settings? Through research, it is critical to establish a fall risk assessment for patients undergoing surgical procedures. Identifying patients who are at risk for falling is the first step in preventing falls in surgical settings. General interventions include providing nurses with education about risks for falling and interventions that prevent falls. Furthermore, nurses in perioperative settings must work together to identify these interventions and assign accountability for preventing falls.
In the case described at the beginning of this column, no one was watching the patient. Each clinician in the perioperative setting must consider the worst possible outcome of a given situation. Observe what is taking place in the OR and ask, "Could the patient fall?"
ESTABLISHING A FALL PREVENTION STRATEGY
Answering the following questions will help facilities establish a fall prevention strategy.
* What safety precautions must be in place when a patient is on an elevated surface, such as a stretcher or OR bed?
* Who is responsible or shares responsibility for monitoring a patient when he or she is on a stretcher or OR bed? Does that responsibility belong to the nurse or to all members of the perioperative team?
* What safety precautions must be in place at all times to ensure patient safety throughout the perioperative phases of care?
* What research must be conducted to develop an evidence-based approach to fall prevention in the OR?
A fall in the OR or in any other perioperative setting can be devastating to both the patient involved and the staff members who care for the patient. Falls are a prevailing risk in perioperative settings and can be prevented by identifying patients at risk and intervening appropriately. Currently, perioperative nurses must rely on knowledge developed using diverse populations and hospital settings to guide practice. To prevent falls, perioperative nurses must collaborate to develop a knowledge base to guide an evidence-based approach specific to the perioperative setting. Using this approach, nurses can determine which patients are at risk of falling and use appropriate information to prevent falls in the OR.
CASE STUDIES
Contributing Factors to Patient Falls
In developing this column, I asked a group of 10 perioperative nurses from a variety of facilities to tell me stories they knew about patient falls in the OR. They provided eight case studies of actual falls and one near-miss account. There were a number of commonalities among the situations. Specifically, falls or near-misses often occurred when the patient was being transferred to the OR bed. In these instances, someone either tried to move the patient without help or did not lock the stretcher before asking the patient to move.
Another problem that contributed to falls was a lack of clear communication about who should be watching the patient after safety straps were removed or before the patient was transferred. Sedation also places patients at risk for falls. Falls or near-misses tend to occur when patients feet fine and try to ambulate before they are steady on their feet. Two nearly identical reports were submitted about patients falling off a fracture table onto their heads, with one fall resulting in a serious brain injury. Two falls resulting in injury were related to positioning. The first occurred when a patient was placed in the Trendelenburg position, and the other occurred when the patient was placed in the lateral position.
Although each of these occurrences is an isolated event, certain commonalities exist. Consider these as you identify fall risks in your work setting and consider strategies to prevent falls.
NOTES
(1.) "2005 Hospitals' National Patient Safety Goals," Joint Commission on Accreditation of Healthcare Organizations, http:// www.jcaho.org/accredited+organizations/patient+safety/05+npsg/05_np sg_hap.htm (accessed 9 Dec 2004).
(2.) "Sentinel Event Alert fatal falls: Lessons for the future," (July 12, 2000) Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho .org/nbout+us/news+letters/sentinel +event +alert/sea_14.htm (accessed 9 Dec 2004).
(3.) A L Hendrich, P S Bender, A Nyhuis, "Validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients," Applied Nursing Research, 16 (February 2003) 9-21.
SUZANNE C. BEYEA
RN, PHD, FAAN
DIRECTOR OF NURSING RESEARCH
DARTMOUTH-HITCHCOCK MEDICAL CENTER
LEBANON, NH
COPYRIGHT 2005 Association of Operating Room Nurses, Inc.
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