JUNE 2023
EDITION 26
THEMES FROM STATEWIDE INPATIENT FALLS SERIOUS ADVERSE EVENTS
Of the 331 SAER reports reviewed, there were 75 reports of death following a fall. 29 patients (40 per cent) were between 80 and 89 years of age (5 per cent of patients were under 65). 50 of the inpatient falls (76 per cent) were unwitnessed. The bedside or bathroom were the locations reported where most falls occurred. Risk factors were related to the patient's physical co-morbidities (89 per cent), confusion or delirium (50 per cent), post fall management (45 percent) and the deteriorating patient (43 per cent). Most of the inpatient falls that resulted in death occurred in General Medicine (31 per cent). The specific service where the other inpatient falls occurred is spread across a range of services including Aged care (11 per cent), Cardiology (7 per cent), Emergency (7 per cent) and Rehabilitation (7 per cent). Collectively, 8 SAER reports refer to a fall occurring in a surgical service (11 per cent). The Clinical Excellence Commission has released a report following a state-wide review of the Harm Score 1 inpatient fall-related Serious Adverse Event Review (SAER) reported between April 2020 to February 2022, to identify recurring themes from findings, identify gaps, and make recommendations for system improvement. Key findings Falls in NSW Health facilities are a significant issue in the older population. Increasingly, older people with multiple co-morbidities are living longer. This has increased admissions of older people to hospitals for care.
Eight key themes were identified
Co-morbidities – Physical Patients with multiple medical conditions or co-morbidities are at an increased risk of a fall.
Communication issues between staff Communication breakdowns between staff about patient risks and care needs contributed, to an extent, to the final outcome.
Failure to recognise cognitive impairment Patients who are confused or have a delirium have been shown to be twice as likely to fall There were reports of delirium screening not completed and failure to implement appropriate interventions in response.
Communication issues with patients and families
Individual patient risk factor identification, intervention strategies and documentation There are reports of failure by health care services and clinicians to appreciate a patient’s risk of a potential fall, through routine risk screening and implementation of an appropriate management plan to mitigate risks for patients, as well as review and revise a patient’s degree of risk throughout their admission. Patient flow and allocation of rooms Several SAER reports revealed that patients were not allocated to an appropriate room suitable to meet their needs for increased observation or supervision. Staff were allocated to patients across multiple rooms, and meant that suitable observation and supervision was not always provided
Generally, there was a lack of early engagement with patients and their families regarding treatment options and expectations relating end of life care. There was considerable family distress noted due to the rapid decline of the patient’s condition as a subsequent result of the inpatient fall.
Medications Polypharmacy increases the risks of falls.
Reports indicate a lack of appreciation of the effect of the use of medications to sedate patients with behavioural issues as a potential contributing factor for a patient fall. There was also a lack of consideration given to patients on anticoagulant therapies and how they can increase a patient’s risk for potential harm following a fall
Post fall care and management Across the SAER reports, there was minimal, or no information included as to whether a safety huddle and a post- fall huddle was undertaken. A post-fall huddle provides an opportunity to engage with the patient, family / carer and to identify what actually happened at the time of the incident and to implement care strategies. Read the full Inpatient Falls Serious Adverse Events Report and access other learnings from incident reviews from the lessons learned intranet page.
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