Recommendations for Fall-Related Injury Prevention

Soncrant, Christina; Neily, Julia; Bulat, Tatjana; Mills, Peter D.

doi:10.1097/ncq.0000000000000408

Cited by 8 publications

(10 citation statements)

References 26 publications

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“…Studies have shown that failure to assess and mitigate falls risk with specific interventions leads to falls (O'Keeffe et al, 2020). Research has shown risk assessment combined with care planning and falls prevention measures, including interventions aligned with identified risks, can reduce falls frequency (Moyer & U.S. Preventive Services Task Force, 2012; Soncrant et al, 2020).…”

Section: Discussionmentioning

confidence: 99%

Using Root Cause Analysis to Inform a Falls Practice Change in the Home Care Setting

Brullo

Rushton

Brickner

et al. 2022

Home Healthcare Now

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years are at particular risk, given the expected age-related increase in the prevalence of MCC (Leslie & St. Pierre, 2009). Diagnoses associated with increased falls risk include heart failure, anemia, depression, diabetes, hypertension, vertigo, and arthritis (Velegraki et al., 2020; Zhao et al., 2020). These conditions and their treatment can compromise physical functioning, placing individuals at greater risk for falling especially when combined with environmental risk factors (Kruschke & Butcher, 2017). Treatment may require polypharmacy, potentially leading to adverse drug events, further increasing the risk of falls (Dhalwani et al., 2017; Leslie & St. Pierre).

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Section: Discussionmentioning

confidence: 99%

Using Root Cause Analysis to Inform a Falls Practice Change in the Home Care Setting

Brullo

Rushton

Brickner

et al. 2022

Home Healthcare Now

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“…Data on falls and fall-related injuries have been systematically collected and analyzed for all nonfederal hospital units since 2011. Although the complementary data sources exist for Veterans Health Administration (VHA) hospitals, there are only a few published studies describing the system-wide burden of hospital falls in the VHA system of care [ 11 , 12 ]. In the past decade, hospital and health care design is increasingly guided by evidence-based design and rigorous research to link the spatial design and built characteristics of hospitals to health care outcomes [ 5 , 13 ].…”

Section: Introductionmentioning

confidence: 99%

Examining the Relationship Between Environmental Factors and Inpatient Hospital Falls: Protocol for a Mixed Methods Study

Shorr¹,

Ahrentzen²,

Luther³

et al. 2021

JMIR Res Protoc

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Background Patient falls are the most common adverse events reported in hospitals. Although it is well understood that the physical hospital environment contributes to nearly 40% of severe or fatal hospital falls, there are significant gaps in the knowledge about the relationship between inpatient unit design and fall rates. The few studies that have examined unit design have been conducted in a single hospital (non-Veterans Health Administration [VHA]) or a small number of inpatient units, limiting generalizability. The goal of this study is to identify unit design factors contributing to inpatient falls in the VHA. Objective The first aim of the study is to investigate frontline and management perceptions of and experiences with veteran falls as they pertain to inpatient environmental factors. An iterative rapid assessment process will be used to analyze the data. Interview findings will directly inform the development of an environmental assessment survey to be conducted as part of aim 2 and to contribute to interpretation of aim 2. The second aim of this study is to quantify unit design factors and compare spatial and environmental factors of units with higher- versus lower-than-expected fall rates. Methods We will first conduct walk-through interviews with facility personnel in 10 medical/surgical units at 3 VHA medical centers to identify environmental fall risk factors. Data will be used to finalize an environmental assessment survey for nurse managers and facilities managers. We will then use fall data from the VA Inpatient Evaluation Center and patient data from additional sources to identify 50 medical/surgical nursing units with higher- and lower-than-expected fall rates. We will measure spatial factors by analyzing computer-aided design files of unit floorplans and environmental factors from the environmental assessment survey. Statistical tests will be performed to identify design factors that distinguish high and low outliers. Results The VA Health Services Research and Development Service approved funding for the study. The research protocol was approved by institutional review boards and VA research committees at both sites. Data collection started in February 2018. Results of the data analysis are expected by February 2022. Data collection and analysis was completed for aim 1 with a manuscript of results in progress. For aim 2, the medical/surgical units were categorized into higher- and lower-than-expected fall categories, the environmental assessment surveys were distributed to facility managers and nurse managers. Data to measure spatial characteristics are being compiled. Conclusions To our knowledge, this study is the first to objectively identify spatial risks for falls in hospitals within in a large multihospital system. Findings can contribute to evidence-based design guidelines for hospitals such as those of the Facility Guidelines Institute and the Department of Veterans Affairs. The metrics for characterizing spatial features are quantitative indices that could be incorporated in larger scale contextual studies examining contributors to falls, which to date often exclude physical environmental factors at the unit level. Space syntax measures could be used as physical environmental factors in future research examining a range of contextual factors—social, personal, organizational, and environmental—that contribute to patient falls. International Registered Report Identifier (IRRID) DERR1-10.2196/24974

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“…Falls are the leading cause of injury-related death in people older than 65 years and the most common cause of nonfatal injuries and hospital admissions for trauma 1,2 . Dementia in older adults increases the likelihood of falls 3–5 .…”

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confidence: 99%

Occupational Therapy Utilization in Veterans With Dementia: A Retrospective Review of Root Cause Analyses of Falls Leading to Adverse Events

et al. 2021

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IntroductionFalls in persons with dementia are associated with increased mortality. Occupational therapy (OT) is a rehabilitation discipline, which has, among its goals, the promotion of safety and fall prevention in older adults and those with dementia. The purpose of this study was to evaluate root cause analysis (RCA) data to identify causes of falls with adverse events in patients with dementia who were referred to or receiving OT services within the Veterans Health Administration (VHA).MethodsThis study used retrospective review of RCAs within the National Center for Patient Safety database for the VHA. The RCA database was searched using these terms: falls with adverse events, dementia, and OT. Descriptive statistical analysis of demographic information, location, occurrence of orthopedic fracture, and mortality was used. All root causes were qualitatively categorized using thematic analysis of determined causes.ResultsEighty RCAs were included in analysis. Mean age of veterans included was 80 years; 96% were male; 76% resulted in hip fracture; and 20% died as a result of the fall. Occupational therapy evaluations occurred within 7 days of admission to VHA and falls most frequently occurred within 4 days of OT evaluation. Most common causes included inappropriate or lack of equipment (21%), need for falls/rehabilitation assessment (20%), compliance/training to fall protocol of all staff (19%), and behavior/medical status (17%).ConclusionsEarlier identification for OT evaluation need may improve access to services, and use of proper equipment to decrease frequency of falls may improve patient safety for older adults with dementia.

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Recommendations for Fall-Related Injury Prevention

Cited by 8 publications

References 26 publications

Using Root Cause Analysis to Inform a Falls Practice Change in the Home Care Setting

Using Root Cause Analysis to Inform a Falls Practice Change in the Home Care Setting

Examining the Relationship Between Environmental Factors and Inpatient Hospital Falls: Protocol for a Mixed Methods Study

Occupational Therapy Utilization in Veterans With Dementia: A Retrospective Review of Root Cause Analyses of Falls Leading to Adverse Events

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