Copyright 2006 Partners Radiology Patient Safety Training “Preventing Patient Falls in Radiology” Partners Radiology Patient Safety Team

Copyright 2006 Partners Radiology

Patient Safety TrainingPatient Safety Training

““Preventing Patient Falls in Radiology”Preventing Patient Falls in Radiology”

Partners Radiology Patient Safety TeamPartners Radiology Patient Safety Team


What is a Fall?What is a Fall?

An unplanned descent to the floor*An unplanned descent to the floor*

*As defined by The Partners Falls Workgroup*As defined by The Partners Falls Workgroup


Did you know that…Did you know that…

25% of people aged 65-74 in the community 25% of people aged 65-74 in the community fall each year fall each year

33% of those over 75 in the community fall 33% of those over 75 in the community fall each year each year

20% of older adults fall while in the hospital 20% of older adults fall while in the hospital

20% of hospital admissions of older adults 20% of hospital admissions of older adults are related to falls are related to falls



15% of falls at home result in serious 15% of falls at home result in serious injuries injuries such as fractures such as fractures

Falls are the leading cause of accidental Falls are the leading cause of accidental death death in people 79 years of age and older in people 79 years of age and older

Hospital stays are often longer for clients Hospital stays are often longer for clients who fallwho fall



In 2001, more than 1.6 million seniors were In 2001, more than 1.6 million seniors were treated in emergency departments for fall-treated in emergency departments for fall-related injuries and nearly 388,000 were related injuries and nearly 388,000 were hospitalized (CDC 2003)hospitalized (CDC 2003)


Risk Factors for Falls Risk Factors for Falls

Extrinsic Extrinsic - Factors outside of the patient's - Factors outside of the patient's body body

Hazardous activities, Time of day, External lighting, Clutter, Hazardous activities, Time of day, External lighting, Clutter,

Spills, Loose electrical cordsSpills, Loose electrical cords

Intrinsic Intrinsic - Factors inside of the patient’s body- Factors inside of the patient’s body

Muscle and strength weakness, Gait and balance disorders, Muscle and strength weakness, Gait and balance disorders, Visual disturbances, Cognitive impairment, Dizziness/Vertigo, Visual disturbances, Cognitive impairment, Dizziness/Vertigo, Postural hypotension, Incontinence, Polypharmacy, Age, Postural hypotension, Incontinence, Polypharmacy, Age, Chronic diseaseChronic disease


Risk Factors for Falls Risk Factors for Falls

Psychological factorsPsychological factors

Anxiety, fear of falling, loss of personal control and Anxiety, fear of falling, loss of personal control and autonomy, dependent relationship with healthcare providerautonomy, dependent relationship with healthcare provider


GoalGoal

““Improve patient safety by providing Improve patient safety by providing tools to assess staff competency in the tools to assess staff competency in the

prevention of patient fallsprevention of patient falls


ObjectivesObjectives

At the end of the training the participant will At the end of the training the participant will be able to:be able to:

– Identify how falls occur (causes)Identify how falls occur (causes)– Identify effects of falls on patient, department Identify effects of falls on patient, department

and hospitaland hospital– Discuss countermeasuresDiscuss countermeasures– Define & deploy the hospital and department Define & deploy the hospital and department

specific falls policyspecific falls policy


MethodologyMethodology

Blame-free ApproachBlame-free Approach – – Share incidents, policies, Share incidents, policies, procedures and risk reduction strategies employed procedures and risk reduction strategies employed

Failure Modes & Effects Analysis Approach Failure Modes & Effects Analysis Approach (FMEA)(FMEA) - - Identify true cause and effects of sentinel Identify true cause and effects of sentinel and adverse events and proactively prevent such and adverse events and proactively prevent such high-risk events from occurring by implementing high-risk events from occurring by implementing selective countermeasures.selective countermeasures.

Root Cause AnalysisRoot Cause Analysis – – Analyze adverse and Analyze adverse and sentinel events retrospectively to identify failures in sentinel events retrospectively to identify failures in systems and processessystems and processes


Target AudienceTarget Audience

All clinical and non-clinical personnel All clinical and non-clinical personnel involved in the management of falls - involved in the management of falls - Techs, Techs, MDs, RNs and Support MDs, RNs and Support StaffStaff


Case Study 1Case Study 1

Patient Falls off Exam TablePatient Falls off Exam Table



45-year-old45-year-old developmentally delayed developmentally delayed woman with large body habitus underwent woman with large body habitus underwent angiography with sedation. angiography with sedation.

Following the procedure the tech went to Following the procedure the tech went to get a stretcher. get a stretcher. When the tech returned to When the tech returned to the patient table, tthe patient table, the nurse began to move he nurse began to move the IV bags to the pole. the IV bags to the pole. The tech rolled the The tech rolled the patient onto her side to place the slide board patient onto her side to place the slide board beneath her. beneath her.


The patient attempted to help by pulling The patient attempted to help by pulling herself to edge of the procedure table. In the herself to edge of the procedure table. In the process, the patient’s body was no longer process, the patient’s body was no longer supported by the procedure table and slide supported by the procedure table and slide board, from which the patient fell to the board, from which the patient fell to the floor. floor. As the patient fell, everyone around tried the As the patient fell, everyone around tried the help but the patient fell and fractured her help but the patient fell and fractured her skull.skull.



What happened?What happened?



What happened?What happened? Post-sedation and cognitive deficiencyPost-sedation and cognitive deficiencyAltered mental statusAltered mental statusNarrow exam tableNarrow exam tableCoordination of team activityCoordination of team activityUnexpected attempt on patient’s part to Unexpected attempt on patient’s part to

helphelp



Large body habitusLarge body habitusPatient unaware of own limitationsPatient unaware of own limitationsNo safety strapsNo safety strapsPatient was not instructed regarding the Patient was not instructed regarding the

transfer proceduretransfer procedure




CountermeasuresCountermeasuresCase Study 1Case Study 1

Provide patient with an explanation about Provide patient with an explanation about the the transfer processtransfer process

Keep safety straps in place until absolutely Keep safety straps in place until absolutely ready to moveready to move



Assure adequate staff available to help in Assure adequate staff available to help in the the transfer – transfer procedures require transfer – transfer procedures require coordinated team effortcoordinated team effort

Patient explanation should include what Patient explanation should include what they they should and should not doshould and should not do

CountermeasuresCountermeasures



Patient transfer from procedure table to Patient transfer from procedure table to stretcher, should include the following stretcher, should include the following measuresmeasures

1.1. Explain procedure to patientExplain procedure to patient

2.2. Gather transfer equipmentGather transfer equipment

3.3. Placement of stretcher next to procedure table with Placement of stretcher next to procedure table with wheels lockedwheels locked

4.4. Lock and level the procedure table with stretcherLock and level the procedure table with stretcher

DiscussionDiscussion



Patient transfer from procedure table to Patient transfer from procedure table to stretcher, should include the following stretcher, should include the following measuresmeasures

5.5. Transfer IV’s, Foleys from procedure table to stretcherTransfer IV’s, Foleys from procedure table to stretcher

6.6. Gather adequate staff to move patientGather adequate staff to move patient

7.7. Synchronize transfer processSynchronize transfer process

8.8. Secure safety rails of stretcher in the upright locked Secure safety rails of stretcher in the upright locked positionposition



Patient Falls During Standing Patient Falls During Standing ExamExam



Mrs. Robinson, an 82-year-old female, came in for a Mrs. Robinson, an 82-year-old female, came in for a routine screening mammogram. She had recently routine screening mammogram. She had recently undergone a knee replacement and was transported undergone a knee replacement and was transported from her car to mammography by wheelchair and from her car to mammography by wheelchair and left her cane in the car.left her cane in the car.The tech asked if she was able to stand and she said The tech asked if she was able to stand and she said yes. The exam was completed with the patient yes. The exam was completed with the patient standing independently. standing independently.



Patient complained during the procedure that Patient complained during the procedure that the compression was uncomfortable. When the compression was uncomfortable. When compression was released, the patient was compression was released, the patient was taken by surprise, became unsteady and fell taken by surprise, became unsteady and fell backwards. backwards.

She suffered a fractured hip, a laceration of She suffered a fractured hip, a laceration of the head and was transferred to the the head and was transferred to the emergency department.emergency department.






Poor assessment of patient’s ability to stand Poor assessment of patient’s ability to stand for the length of the procedurefor the length of the procedure

Patients falls risk assessment not performedPatients falls risk assessment not performedPatient unaware of own limitationsPatient unaware of own limitationsPatients prior history not consideredPatients prior history not consideredAmbulatory aids not usedAmbulatory aids not used




Patient was unable to maintain balancePatient was unable to maintain balanceLack of additional assistance to help patient Lack of additional assistance to help patient

after exam completionafter exam completionPatients response to discomfortPatients response to discomfortPoor explanation of exam procedurePoor explanation of exam procedurePatient off balance from equipmentPatient off balance from equipment




Provide patient with proper explanation of Provide patient with proper explanation of what to expect during and after the exam what to expect during and after the exam including possible discomfort and duration including possible discomfort and duration of examof exam

Conduct comprehensive assessment of Conduct comprehensive assessment of patient’s ability to stand – ask patient to patient’s ability to stand – ask patient to raise their hand if they are feeling weakraise their hand if they are feeling weak




After patient assessment, determine if After patient assessment, determine if additional assistance will be neededadditional assistance will be needed

Keep an ambulatory aid availableKeep an ambulatory aid availableWatch patient during procedure closely (direct Watch patient during procedure closely (direct

visualization)visualization)Make sure you tell the patient when Make sure you tell the patient when

compression is going to be releasedcompression is going to be released





QuestionsQuestions

Which of the following questions are used to Which of the following questions are used to determine falls risk assessment for ambulatory determine falls risk assessment for ambulatory patientspatients

1.1. Have you had any recent falls?Have you had any recent falls?2.2. Do you need assistance to walk?Do you need assistance to walk?3.3. Do you feel dizzy or weak from the prep?Do you feel dizzy or weak from the prep?4.4. What did you have for breakfast?What did you have for breakfast?5.5. How far can you walk?How far can you walk?



Radiology Outpatient Falls ProtocolRadiology Outpatient Falls Protocol• Safety FactorsSafety Factors – – maintain bed in low position, call bell maintain bed in low position, call bell and urinal within reach, offer assistance with elimination and urinal within reach, offer assistance with elimination needs, lock beds, wrist band identification, ambulate with needs, lock beds, wrist band identification, ambulate with assistance, do not leave unattended, maintain patient in assistance, do not leave unattended, maintain patient in constant visual supervisionconstant visual supervision

• Assessment Assessment – – assess ability to comprehend and follow assess ability to comprehend and follow instructions, assess patients knowledge of use of adaptive instructions, assess patients knowledge of use of adaptive devices, evaluate paindevices, evaluate pain

• EducationEducation – – instruct patient and family to call for instruct patient and family to call for assistance with ambulation, transfer or toiletingassistance with ambulation, transfer or toileting



Patient falls from Patient falls from Bed/StretcherBed/Stretcher



Mr. Jones, 47 years old male, is an inpatient Mr. Jones, 47 years old male, is an inpatient who had suffered from stroke with right-sided who had suffered from stroke with right-sided hemiparesis and receptive aphasia, who is hemiparesis and receptive aphasia, who is currently on anti-coagulant therapy. currently on anti-coagulant therapy.

He is waiting in Radiology on a stretcher and He is waiting in Radiology on a stretcher and indicates that he is cold. The tech gets a indicates that he is cold. The tech gets a couple of blankets and puts one on the patient.couple of blankets and puts one on the patient.



The tech goes to get another patient and The tech goes to get another patient and informs Mr. Jones, that if he needs another informs Mr. Jones, that if he needs another blanket to call him. Meanwhile, Mr. Jones blanket to call him. Meanwhile, Mr. Jones is still cold and sees the extra blanket on the is still cold and sees the extra blanket on the table next to his stretcher. He tries to lean table next to his stretcher. He tries to lean over and get the blanket but the side rail over and get the blanket but the side rail gives way and he falls off. gives way and he falls off. He suffers an extension of his stroke He suffers an extension of his stroke causing eventual death.causing eventual death.






Lack of understanding by patient due to Lack of understanding by patient due to aphasiaaphasia

The tech was unaware of patient’s aphasia The tech was unaware of patient’s aphasia – lack of interdisciplinary communication – lack of interdisciplinary communication “critical handoff”“critical handoff”

Equipment malfunctionEquipment malfunction




Patient was left unattended with no direct Patient was left unattended with no direct observation by Radiology staffobservation by Radiology staff

Communication barrierCommunication barrierAltered patient proprioceptionAltered patient proprioception





Follow appropriate equipment Follow appropriate equipment maintenance maintenance proceduresprocedures Check that stretcher side rails are locked Check that stretcher side rails are locked before leaving patient alonebefore leaving patient alone Use judgment before leaving a patient Use judgment before leaving a patient alonealone Get appropriate information from transfer Get appropriate information from transfer

unit on status of patientunit on status of patient




True or falseTrue or false

1.1. Only the nurses on the floor are responsible for Only the nurses on the floor are responsible for the falls prevention program in the hospitalthe falls prevention program in the hospital

2.2. Only transport is responsible for checking side Only transport is responsible for checking side rails on stretcherrails on stretcher

3.3. Falls risk assessment should be communicated Falls risk assessment should be communicated with all care giverswith all care givers

QuestionQuestion



National Patient Safety Goals 2006 - National Patient Safety Goals 2006 - Critical Critical Handoff, Communication & Reduction of Handoff, Communication & Reduction of FallsFalls



Patient Falls While AmbulatingPatient Falls While Ambulating




54-year-old man 3 days s/p CABG X4 54-year-old man 3 days s/p CABG X4 with intermittent atrial fibrillation and with intermittent atrial fibrillation and hypotension. Now with new onset cough hypotension. Now with new onset cough is sent to diagnostic Radiology for CXR is sent to diagnostic Radiology for CXR PA and Lateral. PA and Lateral.

The patient was transported via The patient was transported via wheelchair to the inpatient holding area to wheelchair to the inpatient holding area to wait for his X-ray.wait for his X-ray.



Immediately prior to transport to Immediately prior to transport to Radiology, the patient was administered Radiology, the patient was administered IV Lasix by his nurse. IV Lasix by his nurse.

Shortly after arriving in Radiology the Shortly after arriving in Radiology the patient calls the Radiology associate to patient calls the Radiology associate to assist him with an urgent need to void. assist him with an urgent need to void.



The Radiology associate gave the patient a The Radiology associate gave the patient a urinal and pulled the cubical curtains to urinal and pulled the cubical curtains to provide privacy for the patient.provide privacy for the patient.

The Radiology associate left the patient The Radiology associate left the patient seated in the wheelchair with the urinal in seated in the wheelchair with the urinal in place while he responded to the telephone. place while he responded to the telephone.



The patient could not void while seated The patient could not void while seated and attempted to stand. The urinal began and attempted to stand. The urinal began to fall from position and the patient to fall from position and the patient struggled to catch it. struggled to catch it.

In doing so, he could not free his feet from In doing so, he could not free his feet from the bath blanket, lost his balance and fell the bath blanket, lost his balance and fell forward onto his left shoulder and chest. forward onto his left shoulder and chest.



The patient fractured his clavicle as a The patient fractured his clavicle as a result of the fall and developed a result of the fall and developed a pneumothorax. pneumothorax.







Postural hypotension related to atrial Postural hypotension related to atrial fibrillationfibrillation Lasix (diuretic) potentiating hypotensionLasix (diuretic) potentiating hypotension Inadequate communication between unit Inadequate communication between unit nurse and Radiology departmentnurse and Radiology department



Inadequate supervision of patientInadequate supervision of patient

Patient unaware of own limitationsPatient unaware of own limitations

Patient got entangled in blanketsPatient got entangled in blankets




Provide patient with appropriate level Provide patient with appropriate level supervisionsupervision

Instruct patient not to stand without Instruct patient not to stand without assistanceassistance Communication sheet/Patients pertinent Communication sheet/Patients pertinent history history should be reviewedshould be reviewed




Withhold Lasix until patient returns from Withhold Lasix until patient returns from RadiologyRadiology Provide patient with nurse call lightProvide patient with nurse call light




True/FalseTrue/False

1.1. The only way to give a patient privacy is The only way to give a patient privacy is to leave the patient aloneto leave the patient alone

2.2. Only patients with prior history of falling Only patients with prior history of falling are at risk for fallsare at risk for falls

3.3. Interdisciplinary communication is key for Interdisciplinary communication is key for patient safetypatient safety

QuestionQuestion



Thorough Patient Assessment - Thorough Patient Assessment - Make sure Make sure patient understands and is able to follow patient understands and is able to follow the instructions the instructions

Morse falls Assessment – Morse falls Assessment – Patient specific Patient specific countermeasures countermeasures

Radiology outpatient falls protocolRadiology outpatient falls protocol



PE – Patient effects; HE – Hospital effects; PE – Patient effects; HE – Hospital effects;

RE – Radiology effectsRE – Radiology effects Patient injury Patient injury (PE)(PE) Employee Injury Employee Injury (RE, HE)(RE, HE) Equipment damage Equipment damage (RE, HE)(RE, HE) Patient almost died Patient almost died (PE, RE, HE)(PE, RE, HE) Unexpected or prolonged hospitalizationUnexpected or prolonged hospitalization (PE, HE)(PE, HE)

EffectsEffects



RE – Radiology effectsRE – Radiology effects

Temporary or permanent physical damage Temporary or permanent physical damage (PE)(PE) Pain and suffering for both patient and familyPain and suffering for both patient and family(PE)(PE) Delayed treatment Delayed treatment (PE, RE, HE)(PE, RE, HE) Loss of dignity Loss of dignity (PE)(PE) Fear of falling Fear of falling (PE)(PE) Potential loss of independence Potential loss of independence (PE)(PE)

EffectsEffects


Increased cost for hospital Increased cost for hospital (RE, HE)(RE, HE) Increased length of stay/ICU stay Increased length of stay/ICU stay (HE)(HE) Referring physician loss of confidence Referring physician loss of confidence ( RE, HE)( RE, HE) Litigation issue & Malpractice liability Litigation issue & Malpractice liability (HE, RE)(HE, RE)


RE – Radiology effectsRE – Radiology effects

EffectsEffects


National Patient Safety Goals National Patient Safety Goals 2006 - 20072006 - 2007

Goal 2Goal 2: : Improve the effectiveness of Improve the effectiveness of communication among caregivers.communication among caregivers.

2E - 2E - Implement a standardized approach to Implement a standardized approach to “hand off” communications, including an “hand off” communications, including an opportunity to ask and respond to opportunity to ask and respond to questions. questions.


National Patient Safety Goals National Patient Safety Goals 2006 - 20072006 - 2007

Goal 9: Reduce the risk of patient harm Goal 9: Reduce the risk of patient harm resulting from falls. resulting from falls.

9B9B - Implement a fall reduction program - Implement a fall reduction program and evaluate the effectiveness of the and evaluate the effectiveness of the program.program. Note: Replacement for 9ANote: Replacement for 9A

Documents

Copyright 2006 Partners Radiology Patient Safety Training “Preventing Patient Falls in Radiology” Partners Radiology Patient Safety Team