The study looked at 22 OR patient falls reported to the Veterans Health Administration from January 2010 to February 2016.
Most (68 percent) involved patient falls from the OR bed. Other patient falls (27 percent) happened when the patient was transferred to or from the OR bed and one fall (5 percent) occurred at another time.
Root causes of patient falls were tilting of the OR bed, problems with safety restraints, malfunctioning OR bed or gurney locks, inadequate patient sedation and poor communication among staff.
One fall (5 percent) in the study led to a major injury; four falls (18 percent) resulted in minor injuries; six falls resulted in no injury; and 11 falls (50 percent) had no reported outcome.
The researchers developed recommendations based on the root causes, including guidance on communication, teamwork, best practices, restraints and equipment and training.
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