Falls Risk Guide
Falls
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2005 National Patient Safety Goals requires hospitals to assess and periodically reassess each patient's risk for falling. At Methodist Hospital the total number of reported falls in 2005 was 197 and it is increasing every year, Out of these 80 had reported injuries, 3 had root cause analysis (RCA) completed and 1 was a reportable event. Through RCA we identified that our current falls assessment tool did not accurately capture patients at risk for falls, therefore we had missed opportunities to prevent falls. Further more we did not have many visuals alerting staff that the patient is a falls risk and the visible interventions that correspond with that specific risk.
According to a study supported by the Agency for Healthcare Research and Quality , many falls in hospital happen when the patient is alone or involved in elimination-related activities (for example, walking to or from the bathroom or bedside commode, reaching for toilet tissue, or exiting a soiled bed). Researchers at the Washington University School of Medicine in St. Louis interviewed all patients at one hospital who fell over a 13-week period and/or their family members and nurses. They also reviewed adverse event reports and medical records to identify the circumstances and patient characteristics involved in the first fall of the 183 patients who fell during the study period. The results of their study revealed that the average age of patients who fell was 63.4 years, but ages ranged from 17 to 96 years. Their study showed that 85% of falls occur in the patient's room, 79 % of falls occurred when the patients were not assisted, 59 % during the evening/overnight and 19 % while walking. Nearly half (44 percent) of patients were confused or disoriented at the time they fell. In 81% of the patients general muscle weakness was very prevalent, 39% had diabetes, 36%