by Gina Holiway, MSN, MHA, RN
Accreditation Advisor
10/08/20

No health care worker starts a shift thinking that their patient might be injured in some way while under their care. In fact, health care workers start each shift striving to improve their patients’ health, even if just a little, before they end their day. One of the most common ways a hospitalized patient can be injured is by falling, and those that sustain an injury from a fall have a higher risk of complications that negatively impact their outcome.

I will never forget a patient in my care that fell. It was in the middle of the night and we had an admission from the emergency department. The patient arrived on the unit and was placed in bed in what I believed was a safe manner. I was putting the patient chart together at the nurse’s desk near her room (no electronic health record back then!) when I heard the fall. Every nerve ending in my mind and body came alive. I jumped up and ran to the patient’s room to find her lying on the floor. My heart broke. The patient’s bed had been raised to its highest level and all four side rails were up when she attempted to get out of the bed. While she sustained many bruises, thankfully, she did not sustain any fractures.

Falls programs have been around for many years, but hospitals must continue to evaluate their approach and adopt new strategies to further reduce occurrences. A recent study posted in the New England Journal of Medicine noted a nurse-managed, falls-prevention plan individualized to patients over a 20-month period. The plan’s outcomes did not result in a reduction of serious injuries from falls.

If your organization is accredited by The Joint Commission (TJC), it is important to know that beginning Jan. 1, 2021 the following definition for fall events will be added to its Sentinel Event Policy.

Fall event – Fall resulting in any of the following: any fracture; surgery, casting, or traction; required consult/management or comfort care for a neurological (for example, skull fracture, subdural or intracranial hemorrhage) or internal (for example, rib fracture, small liver laceration) injury; or a patient with coagulopathy who receives blood products as a result of the fall; death or permanent harm as a result of injuries sustained from the fall (not from physiologic events causing the fall).

While reporting a sentinel event to The Joint Commission is voluntary, health care organizations are expected to conduct an internal investigation or root cause analysis whenever a patient fall occurs. With this new guidance from TJC, now is the time to review your falls program and consider incorporating an injury risk assessment into your protocol.

The value of implementing an injury risk assessment

The following are two hypothetical patient examples of why injury risk assessment and prevention should be an integral part of every hospital’s falls program.

The first patient is an 85-year-old female who scores as a high risk for falls using an evidenced-based tool. Incorporating an injury risk assessment would identify that while the patient is a high risk for falls, she is also a high risk for injury if she falls as she is elderly, frail, on multiple medications and has dementia. Interventions will need to be tailored for the patient to mitigate not only her risk of falling but also her risk of an injury should she fall. You can educate and reinforce to the patient to call before she tries to get up but her dementia will not allow her to remember, she has no family with her and you do not have a sitter. You cannot contract for safety (make a verbal agreement) with this patient.

Patient No. 2 is a 57-year-old who does not score as a risk for falls using the same tool. Without an injury risk assessment, the caregiver is not likely to consider this patient as a fall injury risk. However, incorporating an injury risk should the patient fall identifies that this patient was admitted with a deep-vein thrombosis and has been receiving blood-thinning high-risk medications in her intravenous fluids. This patient is not a risk to fall but if she got up and tripped over the edge of the bed or chair and fell, her risk of an injury is high. You explain this to the patient and reinforce the need for her to be mindful of a clear path while ambulating since a fall could cause her severe harm. You can contract for safety with this patient.

These two examples demonstrate how the falls assessment, combined with the injury risk assessment, can guide the care planning for these two patients. Now, clinicians understand the actions needed to reduce the risk of a fall as well as actions to reduce the risk of an injury should the patient fall. Development of the individual care plans should focus on risk categories for example, altered mental status or dementia, impaired gait or mobility, frequent falls and high-risk medications. Additionally, the care plan should be a living document used to communicate continuity of care for a patient. It will encourage caregivers to start talking about injury prevention during shift handoff.

There is an expectation for leaders to provide evidenced based guidelines, cultivate a culture of safety, and support those front-line clinicians who provide safe care. And our patients are relying on us to get it right. If your organization is accredited by The Joint Commission, it is important that you review the definition for fall events that will be included in the TJC Sentinel Event Policy beginning Jan. 1.

It is imperative that falls programs not just assess the risk for falling but also the risk of an injury should any patient fall. The assessments will guide the care planning and actions needed to keep the patient safe. Additionally, communication among caregivers, including family members as appropriate, will help keep the focus on injury prevention.

About the Author:  As accreditation advisor, Gina Holiway, MSN, MHA, RN is responsible for delivering accreditation and regulatory services to hospitals, behavioral health, ambulatory, and critical access organizations. Services include mock survey assessments, coaching during TJC surveys and providing education programs. Gina has over 30 years of experience in health care including patient safety, quality improvement, risk management and experience as a chief nursing officer. As a registered nurse, her clinical experience includes labor and delivery, medical, surgical and emergency department nursing.