Patient falls in the operating room setting: An analysis of reported safety events

Abstract

Introduction: Patient falls are a preventable public health problem, and they are among the most reported safety incidents in the hospital. We used a hospital safety reporting system to examine the nature of reported falls in the perioperative setting at an academic tertiary center. Methods: In this retrospective study, reports of perioperative safety events listed as “Falls” between 2014 and 2020 were analyzed for severity level and specific event type. Results: Out of 8337 safety reports from 2014 to 2020, 86 were “fall” related (1%). The most common “fall” event type was “ambulating with assistance and the severity level reported was mainly level 1 (no harm, did reach patient, 63%) followed by level 2 (temporary or minor harm, 28%). One of the most frequently reported types of perioperative falls was from a bed or stretcher (15% of falls)”. Conclusions: Our safety data reporting system identified falls as a safety event that causes patient harm in the perioperative setting that could be preventable with a multifaceted interdisciplinary approach. Risk managers can use these data to implement strategies to reduce falls such as creating screening protocols to identify high‐risk patients, educating and training healthcare personnel, and optimizing operating room, hospital, and equipment design.

Guidelines in Practice: Safe Patient Handling and Movement

“…• practicing vigilance during induction and emergence of anesthesia. 18 Perioperative nurses should also use a standardized, evidence-based mobility assessment tool, such as the TUG (Timed Up & Go) test, 19 to determine a surgical patient's mobility and if any special handling or mobility technology is needed. 3 Mobility assessment tools evaluate the patient's gait and assess for visual or auditory impairment and mobility assistance requirements.…”

“…Universal fall risk precautions include locking the wheels of patient transport devices, providing patients with antislip footwear, and securing the patient with safety straps during surgery 3 . Individualized fall risk precautions may include providing additional patient positioning support for extreme positions and when positioning patients of size; avoiding distractions when moving, positioning, or repositioning patients; and practicing vigilance during induction and emergence of anesthesia 18 …”