This study was conducted at Barnes-Jewish Hospital, a 1,300-bed academic teaching hospital affiliated with Washington University School of Medicine in St. Louis, Mo. A prospective evaluation of 200 consecutive patient falls was performed from October 22, 2002 through January 25, 2003. All inpatient falls reported for medicine, cardiology, neurology, orthopedics, surgery, oncology, and women and infants services during the study period were included. Falls during physical therapy sessions were excluded because such sessions encourage patients to engage in activities that could cause postural instability, which often results in the physical therapist lowering a patient to the floor without bodily harm. Falls reported from the psychiatry service were also excluded due to the unique risk factors present in these patients.
Patient falls were identified by the data collectors after they were reported by hospital staff into the hospital's secure online adverse event reporting system. A fall is defined within the adverse event reporting system as a sudden unexpected descent from a standing, sitting, or horizontal position, including slipping from a chair to the floor, a patient found on the floor, and an assisted fall. In 2002, the rate of reported falls was 3.29 falls per 1,000 patient-days at Barnes-Jewish Hospital. The fall rate for the time of this study period was 3.38 falls per 1,000 patient-days.
A detailed fall data collection tool was developed based on an extensive review of the literature to identify possible factors contributing to falls and fall-related injuries (). Two researchers, a health systems engineer (EBH) and a registered nurse (PAN), collected data on 200 consecutive falls using this tool. For each event, several data sources were used to collect information including the adverse event database, the electronic nursing charting system (Emtek, Eclipsys Corporation, Boca Raton, Fla), the patient's paper medical record, and an interview with the patient or family member and nurse. The adverse event database included several variables () as well as a description of the fall. The electronic nursing charting system was used to determine health status, medications, and fall risk-level information. If the patient had not yet been discharged, the data collector interviewed the patient and current nurse and reviewed the patient's medical record. The patient or a family member was interviewed for 21% of the cases and a nurse was interviewed for 9% of the cases. Medical records and adverse event reports were consulted for all of the falls. Through interviewing the patient, family, or witness of the fall, or consulting the narrative in the adverse event report, the data collector was able to identify some fall circumstances from a predefined list of possibilities, including the mechanism that triggered the fall (e.g., slipped, tripped, fainted, lost balance), the activity conducted at the time of the fall (e.g., ambulating, getting out of bed, using the toilet), and fall type (e.g., collapse, lowered to floor, fell from height) for some falls. The medical record offered detailed information on the patient's medical history. For example, a patient was considered confused or disoriented if the nurse documented the patient as not being alert to person, place, and time at the time of their fall. Some medical history variables were also obtained by talking with the patient. For example, muscle weakness was assessed by either documentation in the patient's chart or by asking the patient. Impaired memory was assessed by finding documentation of this impairment in the patient's chart as diagnosed by a physical therapist or assessed by the nurse, or by asking the patient or a family member. The data collector also assessed the patient's environment and fall location. Staffing data was collected from nursing staffing records. Fall prevention measures were obtained by consulting the patient's electronic chart or the adverse event report, which includes documentation of such strategies as a special room, bed exit alarm, sitter, toileting schedule, and restraints.
Variables on Fall Data Collection Instrument
Several weeks after the fall, x-ray and CT scan results were reviewed to collect information about injuries discovered after the initial data collection phase. Based on the scale used in the hospital's adverse event reporting system, injury severity was then classified as:
- No injury;
- Minor: minor cuts, minor bleeding, skin abrasions, swelling, pain, minor contusions;
- Moderate: excessive bleeding, lacerations requiring sutures, temporary loss of consciousness, moderate head trauma;
- 4 Severe: fractures, subdural hematomas, other major head trauma, cardiac arrest, and death.
The Washington University Institutional Review Board approved this study. The need for written informed consent from patients was waived because this study was part of a hospital-based quality improvement project and posed no risk to patients. Data were double-entered into a Microsoft Access database (Microsoft Corporation, Redmond, Wash), cleaned, and transferred to SPSS for Windows, version 11.0 (SPSS Inc., Chicago, Ill) for analysis. Pearson χ2 test was used to compare characteristics of patients who fell and circumstances of the fall for categorical variables. Student's t test, ANOVA, and the Kruskal-Wallis test were used to compare continuous variables as appropriate. All tests were two-tailed with P < .05 considered statistically significant. Logistic regression was used to calculate both crude and adjusted odds ratios with 95% confidence intervals for predictors of suffering a fall-related injury.