Betty is a 93 year old lady with a history of falls. Her daughter Barbara talks about what happened when avoidable environmental factors (a cluttered toilet space) interacted with her mother’s risk factor of impaired mobility (for which she was using a walker) to cause a fall.
Watch this short video clip to see Barbara talk about the impacts for her mother and the family (2 mins, 1 sec) or read the transcript below.
Thank you to First, Do No Harm for facilitating and sharing this patient story.
Mum is 93 and does fall occasionally. As the result of a fall she reluctantly went into hospital.
She was ready to come home after five or six days, and I had the call to say she was dressed, ready for discharge. And then within 20 minutes, I had another call from the hospital to say that unfortunately Mum had had a fall and she wouldn’t be coming home. When I got to the hospital I learnt that she’d fallen in the bathroom within her hospital room. There were two or three items of hospital equipment on the bathroom floor it was so cluttered that she couldn’t get out without reversing first. She pushed the toilet seat – which was sitting on the floor as the main obstacle with her foot, and in doing so lost her balance, fell back and smacked her head on the wall.
Mum actually lost her confidence at that point. When she went home from hospital, we had to increase her support. We now have somebody coming in when she showers every morning and we spend a lot more time helping her out ourselves, as well as the care givers that come and go.
Mum going into hospital as the result of a fall should have put up the warning signs. The staff should have been taking extra care to make sure that she was in a safe environment, particularly when she was mobile, using the bathroom.
Patient falls also have an impact on staff and health services. Health professionals often have a sense of dismay and failure when a patient is harmed in a fall, not least because they are aware of the possible outcomes for the patient and family.
Watch this short video clip to see health care staff talk about the impact of falls (1 min, 21 sec) or read the transcript below.
|Denise Le Lievre (Charge nurse manager, neurosurgery, Auckland City Hospital):||When a patient falls, it breaks your heart. You get a real sick feeling in your stomach.|
|Jane Lees (Nurse director, adult, cardiac and cancer services, Auckland DHB):||And the nurses always feel like they perhaps have failed|
|Sandy Blake (Clinical lead, Reducing Harm from Falls programme; Director of nursing, Whanganui DHB):||It’s very upsetting when our patients become harmed from falling.|
|Simon Kerr (Professional leader physiotherapy, Counties Manukau DHB):||The last thing we want, providing care to patients in hospital, is for them to be harmed while they’re here.|
|Denise Le Lievre:||We have a duty of care to keep patients safe, and unfortunately we don’t always achieve it.|
|Simon Kerr:||And falls is one of the most common ways that people are hurt, particularly the elderly, when they’re in hospital care.|
|Dr Shankar Sankaran (Clinical Head and Consultant Physician, Counties Manukau DHB):||To keep one person in a rest home or a private hospital costs about $30,000 a year, so it is a huge amount of money.|
|Jane Lees:||But the cost to the patient is even more. Some patients never even get home after they’ve had a fall with harm. And even if there’s been no harm caused there is often a loss of confidence.|
|Simon Kerr:||…or a worsening of fear. We call it kinesiophobia or fear of movement. That’s very significant.|
|Karen O’Keefe (Clinical Lead, First, Do No Harm):||…and it can really become a socially isolating factor. They don’t feel like they’re comfortable going out, uneven ground, you know, they consider a lot of things and become quite socially isolated.|
|Dr Shankar Sankaran:||Research evidence shows that after a major hip fracture about 25 percent of patients will die within a year after the hip fracture.|
Barbara’s mother, Betty, is a 93-year-old lady with a history of falls, and was admitted to hospital after a fall. Just as Betty was ready to go home from hospital, she fell in a cluttered toilet space which she was trying to negotiate with her walker.
Betty’s hospital stay was extended by several weeks and Barbara described the impacts of this fall for her mother and the family in an earlier video clip.
Watch this short video clip (5 mins, 6 sec), read the transcript below, or download a pdf to read or print here.
|Barbara:||Mum’s experience was really unfortunate, it was just so disappointing that something so simple was neglected and resulted in two weeks of Mum in hospital. I hope that the hospital staff will learn and changes are put in place to make this not happen again.|
|Jane Lees (Nurse Director, Adult, Cardiac and Cancer Services, Auckland DHB):||It makes us feel as though we’ve let the patients down. It’s a very simple thing to keep a place tidy.|
Karen O’Keeffe (Clinical Lead, First, Do No Harm, Northern Region Patient Safety Campaign):
|Learning from the patients and their stories is a huge motivating factor for us. You see the real toll that took on that family.|
Sandy Blake (Clinical Lead, Reducing Harm From Falls programme; Director of Nursing, Whanganui DHB):
|OK, let’s have a really close look at what happened, and why it happened, and we’ll try very hard in the future not to let it happen again.|
|Jane Lees:||But there’s so many people involved in a ward team that somebody has to take responsibility, so what we’ve done is made falls everybody’s business.|
|Sandy Blake:||It’s about the person who brings the cup of tea to the patient. And if they see the patient getting out of bed, and they know that that patient is frail or just looks like they might easily fall, that they push the bell and get some help.|
Simon Kerr (Professional Leader Physiotherapy, Counties Manukau DHB):
|…through to the patient themselves who recognises their own limitations and communicates that to staff, through to the patient’s family, who play a role in that as well, through to the obvious staff members who have that duty of care and that obligation to do their best and ensure patients aren’t harmed when they’re in our care.|
|Sandy Blake:||Most falls occur around the patient’s bed, in the patient’s room, or in the toilet, or heading to the toilet. So it makes us think about what are the things that could help prevent falls in those areas.|
|Denise LeLievre:||This ward has been involved in Releasing Time to Care, which is a lean health care programme that really gave us the opportunity and structure to review our work processes and environment to increase patient safety. So the things that we’ve done are around the environment - we’ve looked at the patient room – we decluttered equipment and furniture in the room. We’ve designed and designated bed sides – so we’ve now got a patient and visitor side, and a nurses side. So that removes hazards when patients are mobilising and also equally allows the nurse easy access to emergency equipment and clinical devices. And out of that, we’ve also developed a patient status board. We assess falls risk on admission and during their stay. The patient status board is a really good visual tool to show and inform the family and the patient of who their nurse is, what their falls risk is and what assistance with mobility they need. We’ve implemented ISOBAR bedside handover where the patient meets their nurse and team at the beginning of each shift. They can ask questions about their care, and also we can complete essential safety checks. It’s a really good visual assessment and with a verbal handover, we can quickly identify the patients at risk. We have daily rapid rounds so we are liaising with our physiotherapists, occupational therapists, speech language therapists and social workers, so it’s a real team approach.|
|Sandy Blake:||Nurses are part of a wider team of people caring for patients but the uniqueness about nurses is that they are there 24 hours a day, seven days a week. They get to know their patients really well, and they understand and think about their patient’s uniqueness. What is it they have to do for that patient to keep them safe?|
|Jane Lees:||Intentional rounding is a process that is being implemented here in this organisation. What intentional rounding does is encourage the nurses to meet with the patient on a regular basis throughout their shift, using intent. They meet the patient at the beginning of the shift and at the patient bedside handover, and makes a contract with the patient so that they will be visiting the patient on an hourly basis.|
|Denise LeLievre:||We’re quite excited about that, because it’s going to give more structure to our nursing care – seeing the patients routinely on an hourly basis and pre-empting their comfort and safety needs.|
|Sandy Blake:||It does make you check on your patient regularly, it does make you address the things that patient particularly needs. Now, if they don’t need help to go to the toilet, you don’t ask them [about that], but you ask them other things that are relevant to them, about their pain, or about them.|
|Jane Lees:||You also use the status bed boards to highlight some of the key areas of concern for the patient in that day.|
|Sandy Blake:||It’s intended to be individualised to the patient. The patient then has trust that you’ll be back at a certain time to help them with the needs that they require.|
|Jane Lees:||We know that our call bell usage has reduced by 50 percent and we know that we have had a reduction in falls. Our data is new, so we can’t see any trends just yet, but we know we have had these reductions.|