Capítulo VI. Conclusiones y Propuestas
6.1 Conclusiones
What happened
A man in his late 60’s fell at home hitting the back of his head. He was admitted to a medium size regional health service for observation of the suspected head injury and investigation of the reason for his fall. He had a variety of medical problems including history of falls, hypertension, osteoporosis, benign prostatic hypertrophy, hiatus hernia and mild obsessive compulsive disorder. The CT scan showed a haematoma and possible venous sinus thrombosis.
The next day this gentleman was provided TED stockings (for preventing blood clots) and the nursing assessment identified that he required assistance to shower and attend the toilet. He was able to mobilise independently with a 4 wheel walker. The nurse documented that his risk of falling was high. The physiotherapist reviewed this man, and developed a plan of care.
Another CT scan was undertaken and there was no evidence of any extension of the injury with the additional notation that the blood collection was subdural rather than extradural.
He was transferred to the Rehabilitation ward for review of reason for falls and ongoing care. He underwent cardiac investigations at a private facility. He is reported as not sleeping well overnight, going to the toilet every few hours.
On the fourth day of admission, nursing staff heard a crash in the ward. They found this gentleman on the floor beside his bed. It appeared that he had tried to mobilise to the toilet using his wheelie walker while he had his TED stockings in place. This gentleman deteriorated and became non‐responsive to painful stimuli.
Following consultation with the tertiary facility, he was transferred for ongoing treatment. Later that day, a craniotomy was performed and the blood clot removed. Over the next few days, this gentleman’s condition improved and after 2 weeks was transferred back to the regional facility for rehabilitation. He received intensive physio and occupational therapy. He was discharged home 3 weeks after that.
Analysis (RCA)
Commodes are not routinely used at night beside patient beds. This is an issue because patients with urinary or faecal incontinence or urgency and at high risk of falls may mobilise unsupervised increasing their risk of a fall.
The use of TED stockings increases the risk of falls in all patients who do not wear appropriate footwear over the stockings when they get out of bed.
The RCA team considered the use of non‐slip socks, but when they consulted PSC, were advised that appropriate footwear (velcro or laced well‐fitting shoes) is recommended by current research rather than non‐slip socks.
Recommendations
1. Review the current practice of not placing commodes at the bedside of patients who are at high risk of falling and who can mobilise with the assistance of walking aids
2. Appropriate footwear is to be used over TED stockings for all patients who have the potential to mobilise independently or with walking aids and who have a high risk of falling.
Discussion
Improving safety does not always need high technological solutions. Simply looking at what happened and to then challenge existing practice, clinicians can and do positively influence their environment. In this situation, a simple decision to encourage the use of commodes at the bedside overnight and ensuring use of appropriate footwear will make it safer for all concerned.
Consumer
Commentary:
Sometimes consumers experience ‘near misses’ which can be frightening or annoying. These include nearly going to an operating theatre for the wrong operation, or almost being given the wrong medication.
When the staff is able to stop these things from happening because they are being careful to double check, it reinforces the confidence we have in them.
Near‐mistakes are a good chance for service‐providers to learn and develop better ways of doing things so that consumers are safer.
No Harm events – why we report them, and why
we sometimes analyse them.
44,353 incidents (78% of the total) were reported where there was no harm to patients. We actively encourage our staff to report such incidents because they are our opportunities to learn.
Some (but not all of these) are “near hits” – that is, a near‐event, averted at the last minute because of staff vigilance. It is imperative that we analyse these and prevent a recurrence, so that future patients are not exposed to the same risk. The best example of this is, for example, if a patient is in the operating theatre before a mix‐ up of patient identity is discovered. Our normal processes should prevent the wrong patient getting anywhere near the operating theatre. If the wrong patient actually gets to theatre, something fundamental has gone wrong somewhere in the system safeguards that precede the bringing of the patient to theatre. Analysis of such “near hits” teaches us a great deal about our healthcare system, so we encourage staff to report incidents even where the patient is not harmed.
Ensuring that lessons are shared and applied
With so much reporting, and the resource committed to analysis, it is timely for us to consider how we gain maximum benefit from the lessons learned in incident management. It makes no sense that incidents must occur in multiple sites before there is learning at multiple sites.
Sharing lessons learned has the potential to minimise patient harm caused by healthcare. Patient Safety Centre has commissioned the Lessons Learned Project to identify and consult with stakeholders to enhance organisational learning from current patient safety data sources.
This work aims to gain insight into the additional patient safety information needs and wants of Queensland Health front line clinicians and managers as well as key external stakeholders such as the Queensland Ambulance Service, the HQCC, general practitioners and the State Coroner.
Consumer
Commentary:
Athough quantifying something like safety is difficult, and is more about the absence of harm, consumers have a role in the evaluation. The more investment consumers have in the process of safety issues, the greater our understanding and the more positive our contribution.
The challenges of measuring
“safety”
We have stressed that this report does not measure “safety performance” – that is, the number of voluntary incident reports is not a measure of safety, other than through the link between a positive patient safety culture and growth in incident reports.
This leaves an untenable situation, where we are presenting data that quite objectively, looks like the system is getting worse, but we are exhorting readers to accept our assertion that, paradoxically, the increase in reported incidents means the system is getting safer.
We do not have an Australian dataset that is agreed as measuring safety. This work is occupying health service providers all over the world.
There is early work being done in Victoria on a set of indicators drawn from hospital coding data, which measures occurrence of discrete events such as complications of anaesthesia or in‐hospital fracture[11]. Some other jurisdictions have progressed this further. The Victorian work is closely modelled on a model from the USA[12], and in April 2009 the European Network for Patient Safety published a recommended indicator set, whilst acknowledging that these require further testing and validation [13].
The complexity of this field is apparent when one considers that the European group have explicitly excluded some of the indicators included by the Victorian group – there simply is no national or international consensus on how best to measure patient safety. Furthermore, there are variations proposed between institution‐ level indicators and system‐level indicators – as evidenced by the variation of each of the above three proposed models from the OECD set of safety indicators, released in 2004.[14]
None of the indicator sets pay heed to patient experience‐ that is to say, none of them have implemented the second “major change” proposed by Lucian Leape – to make our systems patient centric.
Patient Safety Centre is committed to the development and implementation of a suite of patient safety indicators that can be reliably used to measure safety performance. We are contributing to national debate on this issue, and interested readers are directed to a recent peer‐reviewed paper co‐authored by PSC on the issue[15].
Consumer
Commentary:
Falls complicate the health of many patients, and can be prevented easily in many cases.
Consumers feel safer with staff vigilance and strategies to prevent unnecessary falls: e.g. a plan for assistance with mobilising and toileting as needed.
Focus on high risk areas
Falls and Pressure ulcers together account for almost 50% of the harm caused to patients by clinical incidents. Suspected suicides account for over 20% of reported deaths. This section provides detailed analysis of the data we have on these types of incidents, and information about the programs we have to reduce preventable harm.
Falls Injury
Falls are the single largest reason for an injury related admission to hospital and presentation to the emergency department in people over 65 years of age[16]. Along with cognitive impairment and incontinence, falls are one of the major factors in precipitating admission to residential aged care facilities [17].
Older people entering hospital are particularly at risk of falls. The impact of illness, unfamiliar environment, medications, mobility, hearing and visual problems, all contribute to this risk. Implementation of targeted prevention strategies can produce a reduction in falls injury in acute hospitals and residential aged care facilities [18].
Fall Primary Incidents
Staff reported 11,648 fall primary incidents in 2007/2008, a 6.4% increase compared to 10,950 in 2007. The severity of the incidents reported in 2007/2008 was recorded as:
Figure 23: SAC classifications of reported Falls
SAC 1 6 0.05% SAC 2 311 2.67% SAC 3 11,331 97.28%
By definition, falls resulting in death or permanent harm not reasonably expected as an outcome of healthcare should be reported in PRIME‐CI under the primary incident type of “Sentinel Event” with a SAC rating of SAC 1. The SAC 1 fall primary incidents identified above have been reported in PRIME‐CI with a fall primary incident type and may not be representative of all deaths or permanent harm resulting from a fall.
Falls resulting in injury to the patient
Of the 11,648 fall incidents reported, 36% (n=4,289) resulted in injury to the patient. Staff may report one or more injury types for each fall incident.
The SAC rating applies only once to the overall fall incident. Where multiple injuries are reported for an incident, the severity of individual injuries cannot be determined. The site of the injury is not collected in PRIME‐CI.
In 2007/2008, the top three types of reported injuries resulting from falls were 1. skin tear / cut / laceration,
2. bruise / haematoma / contusion and 3. abrasion / graze.
Figure 24: Top 5 Injuries resulting from falls
Injury Type No.
reported
Skin Tear / cut / laceration 2423 Bruise / haematoma / contusion 1104 Abrasion / Graze 960 Head injury 323 Sprain / strain 122 Fracture 107
Falls Risk Assessment
Staff identified that a Falls Risk Assessment was conducted at admission in 84% of fall incidents (9,753 incidents). Where a falls risk assessment was performed at admission, 78% of patients who were reported as experiencing a fall were rated as a High Falls risk (7,628 incidents). These findings are consistent irrespective of whether the consequence to the patient was harm or no harm. Local ward level analysis is required to determine whether interventions were put in place for patients as a result of being identified as a high falls risk and the effectiveness of those interventions that were implemented.
Figure 25: Types of reported falls
Fall Type No.
reported
Overbalance 3216
Patient unable to recollect 3049
Slip 2556
Legs gave way 1636
Trip 565
Dizziness 350
Faint 308
Unknown 1
Figure 26: Place where fall occurred
Place of Fall No.
Reported
Bed / Bedroom / Bedside 6356 Bathroom / Shower Area 1574
Other 782
Toilet Area 742
Corridor 734
Outdoors 462
Dining / Kitchen Area 459 Patient Lounge Area 408 Gym / Pool / Play / Therapy / Activity Room
73 Reception / Waiting Area 30
Medical Imaging 15
Hospital Entry 13
Total 11648
Figure 27: Function or task being undertaken at time of falling
Function at Time of Fall 2007/2008
Not Stated 2717
Toileting 3133
Patient unable to recollect 2401
Resting 1360 Exercising 895 Bathing/ showering 512 Grooming or dressing 473 Use entertainment 224 Total 11648
Figure 28: Top 5 Patient Related Contributing Factors 2007/2008
Factors which Contributed to Fall Incidents Contributing
Factors
% Total
Factors
Patient Factors ‐ High Falls Risk 5643 21%
Patient Factors ‐ Age 4715 18%
Patient Factors ‐ Physical impairments 3183 12%
Patient Factors ‐ Dementia 2938 11%
Patient Factors ‐ Diagnosis / Prognosis / Co‐ morbidities
2101 8%
Queensland Stay On Your Feet ®
Queensland Health has adopted a positive, healthy, active ageing approach to falls prevention. With the permission of the Department of Health Western Australia we are now using the registered trademark Stay On Your Feet® as the main message for falls prevention across the health continuum and the state. This new branding was approved in 2007 by the Department of Premier and Cabinet. A number of health service districts have already adopted the new branding. This branding can be viewed at the Queensland Stay On Your Feet® website:
http://www.health.qld.gov.au/stayonyourfeet/default.asp
Falls Safety Officers Implementation Pilot
An implementation pilot for enhancing Queensland Health’s response to falls prevention in older people: ‘Queensland Stay On Your Feet®‐ in community, hospital and residential aged care facilities’ was conducted over the period February 2008 to January 2009.
The purpose of the project was to trial a strategy to support and coordinate evidence based falls prevention across the health continuum.
The strategy involved the appointment of two Falls Safety Officers (FSOs) (one for public hospitals and residential aged care facilities and another for the community sector) in each Area Health Service (Northern, Central and Southern). These six Falls Safety Officers commenced on 5 February 2008. Priority health service districts and facilities were identified using population ageing projections and hospital falls morbidity data, including hip fractures. [19].
An external evaluation of this project [20] demonstrated that the project has raised the profile of falls and falls prevention activities for older people. The cross‐ continuum approach has been promoted, ensuring that effective strategies are implemented for identifying people at risk at the interface between the community, hospital and residential care facilities and intervening at those junctures.
The Falls Safety Officers completed a total of 39 falls planning or education days, with a total of 920 participants attending, from Queensland Health acute sector staff, Queensland Health community staff, Home and Community Care (HACC), Population Health, public and private and Residential Aged Care, State and Local Government and community Non Government Organisations. On average, representatives from 68.3% of Queensland Health facilities attended the education or planning sessions.
Momentum has been built for falls prevention in Queensland across the health continuum. The formal evaluation provides evidence for the cross continuum model for implementing a state‐wide falls prevention strategy. The lessons learned and wealth of data from this project will inform the next step, which is to develop and
implement a comprehensive and well resourced state‐wide falls injury prevention model so that the work that has been done is sustainable [20].
Queensland Falls Injury Prevention Collaborative
The Falls Injury Prevention Collaborative (FIPC) was formed in 2006. It has a network of over 730 voluntary health professionals who have a role or primary interest in falls prevention across the health continuum in Queensland (See Terms of Reference at
http://www.health.qld.gov.au/stayonyourfeet/documents/33402.pdf). The FIPC
provides a forum to plan, discuss, support and disseminate falls injury prevention initiatives, strategies, research and policy across Queensland Health facilities, other healthcare facilities and the wider community.
The FIPC currently has seven working groups.
1. Falls Specialist Officers:
Two falls specialist officer projects were funded and completed in 2008 at three hospital sites (one at Ipswich Hospital and the other covering both The Prince Charles Hospital and Redcliffe Hospital). Both research projects have been completed and final reports from the research officers have been submitted. The PSC and FIPC will be undertaking a comparative analysis of the Falls Specialist Officer projects and will publish these results by mid 2010.
2. Falls Clinics
Funding was made available to the Northside Health Service District in 2007 to establish a Falls Injury Prevention program. The program consisted of a hospital based Falls Clinic and 2 community based falls prevention programs. A final project report has yet to be submitted for analysis and dissemination of learning.
3. Environmental
This working group has undertaken two research projects in the last year. The first study investigated the use of non‐slip socks for falls prevention. This study concluded that patients are more likely to slip whilst mobilising in non‐slip socks compared to bare feet. Non‐slip socks are likely to offer minor relative traction benefit over compression stockings in dry conditions. This research is being prepared for publication. This group also recently completed the data collection for low‐low bed research project and is being analysed in preparation for publication. This research aimed to investigate whether a program of providing low‐low beds to hospital wards reduces the rate of falls and fall‐related injury.
4. Data and Reporting
This group is working to progress VLADs3 for falls and looking at data linkages where possible to avoid duplication in reports and developing falls indicators.
3
The VLAD methodology was introduced to Queensland Health to aid the monitoring of quality of services provided. It provides an easily understood graphical overview of clinical outcomes over time and plots the cumulative difference between expected and actual outcomes. Selected Private hospitals are also provided with VLADs for certain indicators. The use of VLAD within Queensland Health is governed by the VLAD Implementation
5. Nutrition and falls
This is a new group, formed in 2009. They are exploring ways to create a greater understanding of how nutrition impacts on falling for people aged 65 years and over.
6. Cross Continuum
The Cross‐Continuum Working Group promotes and supports a cross‐continuum focus on falls injury prevention and provides opportunities for an integrated collaborative approach across population health, community health, HACC, acute and residential aged care sectors. This group is chaired by the Population Health Branch. In 2007‐2008, the FIPC Cross‐Continuum Working Group developed with the Queensland Stay On Your Feet® Community Good Practice Guidelines. Dr Nancye Peel, UQ was the lead author. These have been widely disseminated, and are being