On September 28, 2015, The Joint Commission issued a Sentinel Event Alert focused on preventing patient falls. According to the organization, since 2009 it has received 465 reports of patient falls with injuries; about 63% of those events resulted in death. However, the organization puts the actual number of falls nationwide in the hundreds of thousands, with about one third to one half resulting in injury.
And that’s just in hospitals: ECRI Institute has also reported “a significant number of falls occurring in nonhospital settings such as long-term care facilities.” In 2014, falls hit number eight on its annual list of patient safety concerns.
That’s concerning from a patient safety perspective, but the problem has financial ramifications too: One study found that a fall with injury increased the patient’s length of stay by 6.3 days—more than double the average stay of 4.8 days. Each patient fall that results in an injury, The Joint Commission says, costs approximately $14,000.
The group points to a number of factors playing a role in this issue, namely incomplete patient assessment; communication failures; neglecting to follow proper safety protocols and procedures; inadequate staff orientation, supervision, staffing levels, or skill mix; shortcomings in the physical environment; and lack of leadership.
So what does this have to do with healthcare technology management? “Reducing falls resulting in injury is everyone’s responsibility,” the report notes. The Joint Commission goes on to recommend a number of strategies aimed at reducing the frequency of these safety incidents.
Among the proposed steps is an awareness campaign directed toward every level of clinical and nonclinical hospital staff. Each facility should also establish an interdisciplinary fall injury prevention team, or review the makeup of its existing team, to ensure sufficient infrastructure. According to the report, these teams should involve a range of relevant stakeholders—including, I would argue, healthcare technology management.
The Joint Commission also recommends use of a standardized, validated tool, such as the Morse Fall Scale or Hendrich II Fall Risk Model, to flag potential patient risk factors. Patients should receive a risk assessment to develop tailored prevention strategies that attend to their individualized risk factors.
Facilities also need to work on standardizing and incorporating strategies that have already been proven effective, such as a hand-off communication process between caregivers. This system could include the use of white boards to notify incoming staff at shift changes about high-risk patients. It could also involve the integration of alerts, tasks, records, and prompts into the electronic medical record.
Postfall management is critical to identify patterns that can help reduce falls in the future. Incidents should be followed by a “postfall huddle” involving staff at all levels to discuss the events that took place, and how and why they occurred. The discussion should examine whether sufficient resources were in place to avoid the outcome and any contributing factors, such as environmental design. Ongoing data-driven analysis can help identify recurring problems that need to be addressed.
These relatively minor changes can have significant consequences: According to The Joint Commission Center for Transforming Healthcare, the annual savings from fall reduction for a 200-bed hospital total $1 million. For a 400-bed hospital, the savings reach $1.9 million.
Biomeds play a vital role in protecting patients. By bringing their expertise to bear in this arena, they can help solve an important patient safety crisis and add further value to their organizations.
Jenny Lower is chief editor of 24×7. Contact her at [email protected]