Patient falls — a persistent healthcare safety issue — are more often tied to system failures than poor adherence to evidence-based interventions known as fall prevention bundles, according to a recent blog post from ECRI, a nonprofit patient safety organization.
ECRI, previously known as the Emergency Care Research Institute, raised this question: “If evidence-based bundles are in place, why do patients continue to fall — and why do roughly 25% of those falls result in injury?”
“The answer is that preventing falls is not as simple as checking boxes,” the organization said, as falls persist despite many facilities implementing fall prevention bundles. “The bundles themselves are comprised of good ideas, but they are often implemented in a system that makes their successful application difficult, if not impossible.”
The Joint Commission, which has tracked serious harmful events in healthcare since 1996, publishes an annual report on sentinel events. These events are defined as those that result in severe temporary harm, permanent harm or death. Since 2021, patient falls have topped each year’s list.
Patient falls are a complex safety risk, as they can occur for a variety of reasons. Hospitalized patients often are not feeling their best, may be disoriented and might want to have the agency to stand up from their bed — despite clinical instructions and fall-prevention technologies, which sometimes are too late.
ECRI’s blog post stressed that the strongest fall prevention bundles can fail due to system failures, including communication breakdowns, chaotic workplace environments, fall prevention technology that conflicts with frontline workflows, a failure to work with patients or their families, and a blame culture in the facility.
“It’s time to recognize that simply adding more reminders, policies or checklist items to our bundles is not the answer,” the post said. “Preventing falls with injury requires more than that. It requires reengineering the system of care using human-centered design, safety science and continuous evaluation.”
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