Patient Safety in Dialysis Facilities: Preventing Slips, Trips, and Falls

1. ESRD Network 6 5 Diamond Patient Safety Program Slips, Trips, & Falls 2008

2. Patient Safety Patient Safety is a priority In 1999, the Institute of Medicine (IOM) published a report entitled To err is human: Building a safer health care system Report indicates 44,000-98,000 hospitalized patients die annually as a result of medical errors

3. Patient Safety in Dialysis Facilities Falls are most common injury sustained by patients in outpatient arena Major cause of injury and death among elderly and debilitated patients Environmental, physical, and psychological factors contribute to patient falls and ensuing injuries Falls are preventable occurrences that injure patients, cause hospitalizations, and significantly increase healthcare costs

4. Patient Safety in Dialysis Facilities Dialysis patient population is older now - average age of dialysis patients is 65 years of age Co-morbid conditions, dialysis treatment, medications, etc. may affect a patients ability to ambulate Dialysis environment is vulnerable to slips, trips, and falls due to use of water and many other liquid products Slips, Trips & Falls are preventable occurrences

5. Slips, Trips, & Falls Prevention Program Because of the limited research on slips, trips, and falls in dialysis facilities specifically, a large study completed in the UK on slips, trips, and falls in hospitals is cited and gives valuable insight on causes and circumstances; lessons learned; and prevention of falls and reducing injuries

6. UK Study on Slips, Trips, & Falls in Hospitals February 2007 the National Patient Safety Agency- NHS (UK) launched their third report from the Patient Safety Observatory, Slips, trips and falls in hospitals Report highlights the scale and consequences of patients falling in hospitals Report analyses largest dataset of falls in hospitals in the world Goal of report was to understand the scale & consequences of patient falls in hospitals & to suggest interventions that, when used together, can reduce falls and injuries National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

7. UK Study on Slips, Trips, & Falls in Hospitals Over 200,000 falls were reported to the National Reporting and Learning System (NRLS) Timeline: September 2005 - August 2006 Results hip fractures broken bones death prolonged hospitalizations extra medications surgery National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

8. UK Study on Slips, Trips, & Falls in Hospitals Report uses NRLS data Data on patient safety from other sources Questions asked: where falls were occurring why falls were occurring target patient groups most likely to fall how falls are being reported What measures were in place to prevent falls National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

9. UK Study on Slips, Trips, & Falls in Hospitals Reasons why patients fall are complex and influenced by various contributing factors such as: physical illness mental illness medication age environmental factors National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

10. UK Study on Slips, Trips, & Falls in Hospitals Falls can be result of a single factor such as: tripping fainting Most falls (particularly in elderly) are result of several interacting factors such as: walking unsteadily being confused being incontinent or needing to use the toilet frequently having fallen before taking sedatives or sleeping tablets National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

11. UK Study on Slips, Trips, & Falls in Hospitals Cause & Circumstances Key Messages Why patients fall: What patients were doing when they fell: Most falls are result of combination of factors Poor mobility and confusion are often contributing factors Environmental hazards such as wet floors or steps are identified in only a small proportion of patient falls Most falls occur while patients are walking Patients are particularly likely to fall while using the toilet or commode Patients most vulnerable to falls: Learning from the circumstances of falls: Older patients, particularly those aged over 80 Relative to the proportion of men and women in hospitals, there are more reported falls of men than women This can help organizations to direct their resources to where they are most needed Some reports (documentation) of falls are too brief to support local or national learning When patients are most likely to fall: Recommendations to organizations: Weekdays, when there are more patients in hospitals mid-morning (10-11AM), when patients are most likely to be active Fewer falls occur at mealtimes and in the early hours of the morning Make sure that the circumstances of falls are described completely and meaningfully on incident/adverse occurrence forms Analyze and use reports of falls to learn from ward to board level Staff witnessing patient falls: Only a minority of falls are witnessed by staff Even when a member of staff witnesses a fall, they are unlikely to be able to stop the patient from falling National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

12. UK Study on Slips, Trips, & Falls in Hospitals Prevention & Reduction of Injuries Key Messages National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author. Fall risk scores are not an essential part of falls prevention policies: Wristbands, symbols and observations: Checking directly for modifiable risk factors may be more effective Even the better falls risk scores will under-or-over predict patients falls A proportion of organizations are using un-validated falls risk scores Any falls risk score needs to be tested in the hospital where it is used If falls risk scores are used, there also needs to be a second stage of assessment looking for modifiable risk factors Some hospitals give patients at high risk of falls special wristbands or bedside symbols, but there is not evidence that they reduce the number of falls Extra wristband with different colors may introduce new risks One-to-one observation may not always be feasible or effective in preventing falls

13. UK Study on Slips, Trips, & Falls in Hospitals Prevention & Reduction of Injuries Key Messages National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author. Using multifaceted interventions: Patients views on interventions to prevent falls: Theses are interventions linked to the risk factors that can be modified in individual patients They may reduce the number of falls in hospitals by 18 percent It is less clear whether they are as effective for patients with dementia Patients views must be taken into account in planning interventions to reduce harm from falls in order to balance dignity and independence with risk of harm The environment: Cost benefits of preventing falls: Improvements to lighting, flooring, trip hazards, ward design and furniture may reduce the risk of falls There is no clear evidence that a particular type of flooring reduces injuries The financial cost of falls prevention policies in hospitals is not known, but successful programs have been introduced with limited resources Multifaceted interventions could produce an 18 per cent reduction in the number of falls Savings from reviewing less effective interventions could also be reviewed

14. UK Study on Slips, Trips, & Falls in Hospitals Prevention & Reduction of Injuries Key Messages National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author. Technology to prevent falls and injury: After a fall: There is not enough evidence to recommend the use of hip protectors in hospitals There is not enough evidence to recommend the use of alarm devices Falls can be a symptom of underlying illness Early detection and treatment of injuries is needed Observations and checks for injury after a fall appear to vary between organizations Unless a first fall leads to a review, including medical assessment, the patient is likely to fall again

15. UK Study on Slips, Trips, & Falls in Hospitals Summary A range of interventions, used together and tailored to reduce individual patients specific risks can be effective. Possible interventions include: Reviewing medication associated with a risk of falling Detecting and treating causes of delirium Detecting and treating cardiovascular illness Detecting and treating or managing incontinence or urgency Detecting and treating eyesight problems Providing safe footwear Physiotherapy, exercise and walking aids National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

16. UK Study on Slips, Trips, & Falls in Hospitals Summary Many aspects of a hospital or dialysis facility environment may have an impact on the risk of falls or injury. These include: Flooring surface and pattern, and hardness or softness of floor Lighting, including sudden changes from dim to bright lights The design of doors and hand rails The layout of toilets and bathrooms The distance and spaces between hand hold, beds, chairs and toilets The line of sight for staff observing patients Trip hazards, including steps, clutter and cables Furniture and medical equipment National Patient Safety Agency. (2007, February 26). Slips, trips and falls in hospital (3 rd Report from the Patient Safety Observatory). United Kingdom: Author.

17. Slips, Trips, & Falls Prevention Program Goal identify patients who are at risk Institute proactive efforts to reduce the occurrences of slips, trips, & falls related incidents Provide a safe environment for dialysis patients