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December 2008

Target Key Risk Factors to Reduce Falls -- by Robin Walters, RN, BSN

37469435 Patient falls top the list of the most frequently reported adverse events for hospitalized adults. Even with possible under-reporting, rates of inpatient falls range from 1.7 to 25 per 1,000 patient days, depending upon the area of the hospital in which patients receive care . This translates to falls occurring among 1.9% to 3% of all acute care hospitalizations, totaling as many as one million falls per year.


Serious injuries occur in 2% to 8% of acute care falls, resulting in about 90,000 serious injuries and 11,000 deaths each year in the U.S. And according to the CDC Web site, up to 75% of nursing home residents fall each year. Among these, serious injuries occur 10% to 20% of the time, leading to approximately 1,800 deaths annually.

Hospitals that participate in national reporting databases such as the American Nurses Association, National Database of Nursing Quality Indicators(ANA-NDNQI) can compare their rates of falls and injuries to similarly-sized hospitals with comparable types of patients.


Patients in rehabilitation, behavioral health, and oncology settings are at higher risk for falls.  Pediatric patients are at much lower risk, possibly because parents tend to stay with children, providing increased supervision. The five main risk factors for falls among all types of patients are: side effects from medication, gait problems, increased toileting needs, a history of falls, and—perhaps most significantly—confusion. Extrinsic risk factors include: inadequate lighting, objects in patient rooms that are colored so similarly to the room itself that they are hard to distinguish, and poorly-placed handrails


When hospitalized patients fall and are injured, hospital charges rise by about 60%.  The impact on a hospital’s bottom line is likely to grow now that Medicare, as well as many private insurers, will no longer reimburse for diagnoses resulting from injuries caused by falls during the hospital stay.


Of all the hospital acquired conditions on the “no-pay” list, falls can be the most difficult to prevent. Instruments to assess patient risk for falls and injuries have been unreliable, and a review of the literature raises questions about the effectiveness of today’s fall prevention programs.


The evidence does support focusing on each patient’s most important risk factors for falls and using a combination approach to prevention, including the following practices:

  • Review and monitor medication side effects

  • Treat contributing conditions such as anemia, syncope and impaired vision

  • Check confused patients for toileting needs every two hours

  • Educate staff about risk factors for and prevention of falls

  • Use bed/movement alarms

  • Make environmental changes (e.g., better room design)

  • Conduct post-fall assessments

Robin Walters, R.N., B.S.N., has been privileged to provide care in hospitals, clinics, schools and physician offices, at sites ranging from large urban to remote rural. Be sure to also read Robin's other contributions on bloodstream infections, hand washing compliance, and culture of safety.

New Resources on Adverse Events in Hospitals

OIG report The U.S. Department of Health and Human Services Office of the Inspector General(OIG) has just released two new reports on adverse events in hospitals.  These are the start of a series of reports that the OIG will be issuing to Congress to comply with the Tax Relief and Health Care Act of 2006.   The Act mandates that OIG keep Congress up to date on the incidence of adverse events among Medicare beneficiaries, the payments associated with care related to the adverse events, and the processes for identifying and denying payments for such events.

The first, entitled Adverse Events in Hospitals: Overview of Key issues, identifies seven areas of importance for understanding the "landscape" of these events.  In addition, the report identifies strategies for reducing the incidence of adverse events.  The findings are based on interviews with a vast array of stakeholders.

The second, Adverse Events in Hospitals: State Reporting Systems, outlines the existing State programs and how the States use the data they collect.  As of January 2008, 26 States had implemented reporting systems and another one was in the works.  Twenty three of the States use their systems to hold hospitals accountable, while 18 use the data to promote learning and prevent adverse events.

AHRQ Report Shows Pressure Ulcers in Hospitals on the Rise -- by Suzanne Delbanco, Ph.D.

16354589 A new report issued by the Agency for Healthcare Research and Quality (AHRQ) suggests that pressure ulcers among hospitalized patients have become significantly more prevalent over the last fifteen years.  Based on data from the Healthcare Cost and Utilization Project (HCUP), the analysis found that in 2006 there were more than 500,000 hospital stays with pressure ulcers noted as a diagnosis as compared to during about 280,000 in 1993 - an increase of almost 80%.

These numbers include both patients who were admitted to the hospital for treatment of pressure ulcers as well as those who developed them during a hospital stay for treatment of some other condition.

Pressure ulcers - commonly referred to as bed sores - can be very painful for patients and can lead to life threatening infections and added costs.  Any patient with impaired mobility can be at risk as pressure ulcers are typically caused by very long "periods of uninterrupted pressure on the skin, soft tissue, muscle and bone," according to AHRQ.

Severe pressure ulcers are considered serious reportable adverse events, or "never events," by the National Quality Forum, and are on the list of Hospital-Acquired Conditions for which the Medicare program will no longer elevate hospital reimbursement.

There is no national agreement on which is the best protocol for the prevention of pressure ulcers - or which protocol helps keep existing pressure ulcers from becoming more severe.  However, Arrowsight Medical's Hospital Video Auditing methodology can help hospitals track how often clinical staff are changing the position of at-risk patients, which could significantly aid in the refinement of protocols and lead to dramatic improvements.  Arrowsight is eager to partner with hospitals to turnaround the disturbing trends identified in AHRQ's report.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

New Study Questions Impact of Rapid Response Teams

36411739 A study published today in the

Journal of the American Medical Association calls into question whether rapid response teams have an impact on hospital-wide code or mortality rates.


Rapid response teams are multidisciplinary teams of experts in intensive care that evaluate, triage, and treat patients outside of intensive care units who are showing signs of deteriorating.  The purpose is to reduce in-hospital cardiopulmonary arrests (codes) and the subsequent morbidity and mortality.

At St. Luke’s Hospital in Kansas City, Missouri, researchers conducted a prospective cohort study of adults admitted between January 1, 2004 and August 31, 2007.  The rapid response team education and program was launched in the last quarter of 2005.  Examining more than 24,000 admissions both before and after the intervention and 376 rapid response team activations, there was no association between the use of rapid response teams and reductions in hospital-wide code rates or mortality.

The Institute for Healthcare Improvement and others have been touting rapid response teams as an important means to reducing hospital mortality.  The study raises questions about whether hospitals should invest financial and other resources if rapid response teams do not reduce mortality.

Fatigue Among Medical Residents Dangerous for Patients

Yawn The Institute of Medicine has released a new report that stresses the need for reforms to medical resident education and work hours. 

While in-depth, first-hand experience caring for patients is a critical aspect of medical education, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety suggests that the long hours residents work and the resulting fatigue contribute to medical errors.  The report argues that the workloads and duty hours for residents should be revised both to protect patients from mistakes as well as to enhance the learning experience for the residents.  Specifically, the report recommends regular opportunities for sleep each day and each week during training.  It suggests that the Accreditation Council for Graduate Medical Education enhance its monitoring of duty hour limits and that residency review committees create guidelines for the patient caseloads given to residents.  The report also recommends that residency programs enhance supervision of their residents as well as improve their procedures for the handover of patients. 

More statistics on preventable medical errors located here.

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