Learning from in-patient falls: Analysis of a sample of reported serious adverse events

Learning from in-patient falls: Analysis of a samp…
01 Nov 2013

Patient falls resulting in harm are one of the most frequently reported adverse events in hospitals. Of the 730 serious adverse events reported by district health boards (DHBs) in New Zealand in 2010–12, 365 were patient falls (averaging one every other day); of those, 170 were associated with a hip fracture, typically adding an estimated month to an individual’s hospital stay. The financial cost to the health system, at a minimum, was an additional $2.6 million. This is only a fraction of the total harm associated with falls in hospitals, and all harm in hospitals is only a fraction of the total harm associated with falling in care settings.

Of those who suffer a hip fracture, half will require support with daily living or mobilising; and 10–20 percent will be admitted to residential care as a result of the fracture. Of older people who fracture their hip, 27 percent will not be alive a year after the fracture.

The Health Quality & Safety Commission’s Reducing Harm from Falls programme aims to:

Reduce harm from falls by supporting interventions which prevent falls and reduce falls-related injuries – in older people at risk, defined as those aged 75+ (Māori/Pacific peoples aged 55+) in care settings (ie, hospital inpatients, people in aged residential care and those at home receiving care), and those with polypharmacy or previous fragility fracture.

There is no single solution to reducing patient harm from falls. An essential first step is to identify a patient’s risks of falling, then develop a care plan addressing those risks. Risk assessment and care planning are the two principle processes being promoted by the Falls programme to bring about quality improvement, and measured through the Commission’s quality and safety markers (QSMs).

The aim of the review was to learn from patient falls with serious harm reported as serious adverse events by DHBs to the Commission. The review was designed to determine what can be learnt from a subset of events reviewed by DHB teams. The intention was to identify key findings, including contributing factors to the falls events, and recommendations on preventing those falls.

The questions asked during the review relate to maximising learning and improving analysis and reporting.

  1. What can be learned from the contributing factors identified in the reports submitted? What should all stakeholders, but especially health care teams and the Falls programme team, prioritise?
  2. What recommendations were documented in the reports and what can be learned from those recommendations?
  3. What can be said about the analysis process and can any recommendations be made to improve the analysis and reporting process?

In answering the above questions, a number of assumptions were made.

  • Analysis was undertaken by knowledgeable and skilled people and teams.
  • Key findings and recommendations will potentially offer lessons in other health care settings.
  • The human factors methodology offers a useful framework for further analysis of DHB reports.
  • Analysis of a sample of DHB reports may support the development and refinement of a falls-specific human factors framework.
Page last modified: 15 Mar 2018