Falling Into Risk Reduction Opportunities
By Kathy Cartwright, BSN, RN, CPHQ, LNCC
Falls represent a large percentage of office and surgical accidents reported to SVMIC. Falls have also generated considerable attention from patient safety organizations. The Centers for Disease Control and Prevention have developed an initiative specifically addressing patient falls in their “STEADI” (Stopping Elderly Accidents, Deaths and Injuries”) program.  Additionally, the Journal of the American Medical Association noted that falls among US adults, aged 65 and older, is a leading cause of fatal and non-fatal injuries. Although these injuries may seem relatively minor for most patients, it would be impossible to predict which patients will have a fatal vs. a non-fatal injury if a fall occurs. With that in mind, it is in everyone’s best interest to eliminate the possibility of any fall whenever possible. Graph 1 identifies overall the types of accidents reported.
Of all office accidents reported to SVMIC, falls occur in the largest percentage of these events. In addition, the majority of falls result in injuries that are temporary in nature, indicating that after a period of recovery, the patient is able to resume their previous level of independence. Some falls did not result in any physical injury at all and only a small percentage of the falls resulted in a permanent injury. None of the falls occurring in an ambulatory setting resulted in a death.
These graphs illustrate that the majority of office accidents in an ambulatory setting involve a fall, but the majority of the falls result in temporary or non-physical injuries. However, falls create interruptions and take you and your staff away from other patients in the office. You spend additional time examining the patient and evaluating possible injuries, which frequently requires ordering diagnostic tests and arranging transportation to an emergent care setting. The cost to you in time and resources creates motivation for the prevention of these office accidents.
Consider the possibility of this scenario occurring in your office:
An elderly patient was brought to your office for routine follow-up care, triaged by the nurse, and left sitting in her wheelchair in the exam room, unattended. Before the nurse returned to the exam room with the physician, they heard a “thud” coming from the room and rushed in to find the patient had fallen from her wheelchair, hitting her face on the nearby counter. The office staff quickly arranged immediate transportation of the patient to the local ER via ambulance, where it was determined that she sustained a nasal fracture, as well as a cervical fracture. The patient required additional medical care for her injuries. Later, the office staff determined that the nurse left the room without locking the wheels of the wheelchair.
This type of accident is preventable but requires implementing modest patient safety changes in office procedures. Patients in wheelchairs should always have the wheelchair locked when they are not moving from one location to another. It would also be advisable to avoid leaving wheelchair patients unattended, and especially if they cannot stand on their own. This may require that they remain in the lobby with their caregiver until both the physician and the nurse are able to examine the patient, reducing the possibility that the patient will have to wait for the physician after the nurse completes the intake information. If the patient gives a family member or caregiver permission to accompany them to the exam room, they are also a good option to stay with the patient if the nurse or physician cannot. SVMIC recommends documenting the patient’s mentation and mobility status, as well as the precautions that the staff took to protect the patient’s safety.
In another case, a 59-year-old female underwent lumbar steroid injections in the office without any complications. A few minutes after the procedure, the nurse evaluated the patient and confirmed that she was able to stand and bear weight. The patient indicated that she was able to change her clothes by herself, and told the nurse it would be fine for her to leave the patient while she changed. However, while the patient was changing, she lost her balance and fell on her shoulder. An x-ray revealed a shoulder fracture and required surgical repair.
This patient seemed to be able to stand on her own after her procedure, which resulted in the nurse allowing her to dress without assistance.
Many times patients don’t realize how weak or unsteady they are until they make an effort to engage in activity, such as getting dressed, which may induce the dizziness and unsteadiness that led to this patient’s fall. In the absence of having a family member or caregiver that can assist the patient, providing him/her with the assistance of a nurse may be the best way to ensure that the patient does not have an accident that will result in this type of harm.
Although it is rare to see a fall in the ambulatory setting with a devastating outcome, there have been cases where those occurred. In one case, a 43-year-old male seen in an office for an upper respiratory infection received intramuscular antibiotics during the office visit. The nurse asked the patient to lean over the exam table while standing so that she could administer the medications into his gluteal muscle. When the nurse administered the medication, the patient fainted and, as he fell, his head hit the wall next to exam table. The physician immediately assessed the patient and the office arranged for transport via EMS to the closest emergency room. Imaging studies identified a skull fracture with subarachnoid bleeding. The patient sustained permanent injuries and now requires assistance with activities of daily living. This case resulted in litigation in which the failure to develop policies for giving injections safely and the failure to train the staff on these policies were the primary allegations. If the staff member who administered the medications had implemented safe injection precautions to reduce the possibility of a fall, the result of receiving these injections may have been very different.
Frequently, a patient falls after receiving an injection or having a venipuncture performed. Sometimes a fall occurs after a patient takes medication, i.e., a sedative, for a test or procedure and attempts to walk or stand before it wears off. Almost half of all falls occurred in an exam room, but other locations included the hallway, lobby or the phlebotomy chair.
Many of the situations that result in a patient fall are preventable. The CDC has several resources available for healthcare providers designed to assist in screening and reducing fall risk. You can find this information here.
SVMIC also has an online educational program titled “Patient Safety in the Physician Office Setting” which is available here. The Course Catalog contains the information for registering and taking this course. This course provides additional suggestions for improving the safety of the physician office setting.
By taking steps to eliminate the potential for a patient fall, you will be able to improve patient safety and also reduce liability risk in your office. With that in mind, use these suggestions to create or enhance your patient safety policies:
- Identify patients who may be at risk for a fall
- Patients who have medical procedures, such as venipunctures or injections, which may create anxiety or pain
- Patients who are elderly or adolescent
- Implement measures to reduce the risk of a fall
- Offer a beverage and/or reassurance about the procedure to reduce anxiety
- Have patients sit or lie down during the procedure and then assist them to a safe location after the procedure is finished for them to wait until they have been observed
- Observe all patients for a period of time after an injection or venipuncture to ensure they are not dizzy, weak or unable to ambulate to their car
- Assist all patients with mobility limitations or visual impairment with moving off exam tables, out of the office and into their car
- Do not leave patients alone in an exam room after a procedure – if a family member or friend did not accompany them to the office, designate someone in the office to stay until the required waiting period is complete
- Be sure that wheels on equipment, stools or other furniture are locked when not in use. If there is not a wheel lock available, consider marking the equipment “Staff Use Only” to discourage patients or their family from using it
- Determine if the patient is oriented and able to follow instructions before leaving them alone after a venipuncture or procedure. If the patient does not understand that he/she should not attempt to walk alone, a friend or family member may need to stay with him/her if your staff is not available
- Document the patient’s condition on presentation to the office
- The assessment of the patient's mentation
- Instructions given regarding activity limitations
- Safety measures employed and assistance offered
- Refusal to accept assistance/follow the directions
Although falls may not be common in your office, the adage that “an ounce of prevention is worth a pound of cure” could not be more appropriate when applied to this topic. As we have learned from this study, most falls do not result in large lawsuits with paid losses. However, the injury sustained by the patient, as well as the staff time associated with addressing the patient’s care needs, creates a complication in your day. By improving your patient’s experience with a few basic safety measures, you will find yourself falling into risk reduction opportunities and saving time and resources for your practice.
 Older Adults’ Falls Take High Toll. JAMA. 2016;316(18):1860. doi:10.1001/jama.2016.15623
The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.