Falls THE ISSUE OF ACCIDENTAL FALLS

At some point, anyone who had learned how to walk has had the experience of falling down -- it is a universal experience for infants as they gain ambulatory ability. In hospitals, however, the accidental fall is the most reported type of patient safety incident, with elderly patient populations displaying a particular vulnerability (Oliver 2007, p.173). Approximately one-third of adults over the age of sixty-five will experience an accidental fall this year (CDC 2012, n.p.) Fischer (2005) offers some clarification as to how these incidents should be defined -- the simplest basic definition is "a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object" (p822). This definition takes into account the unpredictable nature of the incident, and the fact that it frequently involves a certain loss of control on the part of the patient; it also reminds us that the fact that a patient can fall onto some "other object" may indicate a whole range of unforeseen damaging consequences involved in a fall.

Fischer (2005) rather crucially distinguishes different types of falling incidents -- obviously with a phenomenon as common as the accidental fall during a hospital stay, it is possible to make some broad categorical generalizations -- and offers two related phenomena, the "near fall" which is understood as a sudden loss of balance in which the patient never actually makes impact, and which would cover such actions as slipping, stumbling or tripping without subsequent impact injury (but still entirely capable of causing injury in the form of strains, sprains, bruises, or in various other ways) and the familiar hospital event of the "un-witnessed fall," in which a patient is discovered on the ground and no-one, including the patient, can describe how the patient got there (Fischer 2005, p.548). Oliver (2007) notes that, in terms of overall statistics, "most falls are unwitnessed by staff" in hospitals (p.177). If there are a variety of different ways for a patient to fall down and be injured, however, there are also numerous significant consequences for the accidental fall. Oliver (2007) gives a useful summary of the various possible consequences: accidental falls can, of course result in physical and psychological harm, up to and including more long-term functional impairment; accidental falls can prolong a patient's time in hospital, and substantially increase the cost of care; they are also a liability concern, provoking concern or outrage from the family of a patient, including frequent complaints, demands for inquests, and even lawsuits (pp173-5). In Oliver's (2007) assessment, accidental falls must therefore be included in any reasonable institutional strategy for risk management within a hospital, despite the fact that the amount paid out in damages for accidental falls amounts to "a relatively modest sum" (p.177). It is not the potential financial consequences of accidental falls that should concern hospitals, in the assessment of Oliver (2007), but instead the sheer volume of such accidents and the attendant claims upon them: after surveing the data, Oliver concludes that accidental falls account for "nearly 50% of all critical incidents" (p.177). The CDC states that, statistically speaking, accidental falls are "the most common cause of nonfatal injuries and hospital admissions for trauma" (2012, n.p.)

II. ACCIDENTAL FALLS: IDENTIFYING THE PROBLEM

The difficulty here is that accidental falls are not really a medical condition in and of themselves -- in reality they are frequently a result of the patient's illness or overall frail physical condition which necessitated a hospital stay in the first place. The absolute frequency of accidentall falls therefore should not be taken as a sign of negligence in medical care, or a symptom of a dysfunctional hospital system -- it has been established that the rate of accidental falls depends upon the medical condition of the patients who suffer them, and therefore an overall "rate" of accidental falls for a hospital facility overall is likely to seem misleading if it is not considered with adjustment for the rates specific to individual hospital units, with an eye on the specific patient populations within those units (Oliver 2007, p. 175). This presents a substantial institutional difficulty, though, in the operation of the average hospital: there are reported large variations in the rate of accidental falls, and it raises a question about standard of care. Should some falls (for example, with frail elderly patients) be regarded as essentially unpreventable? The difficulty here seems to be the risk of what Oliver...

177-8). According to CDC statistics, however, the question of ageism may be precisely relevant: less than half of adults over the age of 65 will actually talk to their doctor about having fallen, presumably because of the general assumption that to admit to having suffered an accidental fall is, in some way, an admission of declining capability (CDC 2012, n.p.) Besides, with such a wide-ranging variety of potential incidents, it is not really clear what sort of strategy an institution should pursue -- acting out of fear of potential lawsuits over an accidental fall may, in fact, lead hospitals to pursue strategies of intervention which do not actually work, and are not even based on any particular assessment of the medical evidence (in terms of, say, an examination of whether installing larger bedrails on hospital beds actually increases or decreases the rate of falls related to a patient getting into or out of bed). Oliver (2007) notes that evidence from studies on the subject shows that, while it is possible to achieve a slight-to-moderate reduction in the overall rate of accidental falls, it does not seem to affect the number of actual patients undergoing the accidental falls.
III. ACCIDENTAL FALLS: SIGNIFICANCE OF THE PROBLEM

CDC statistics indicate that, in the year 2008 alone, nearly 20,000 adults died from injuries related to an accidental fall -- accidental falls are recorded as the leading cause of injury death among adults 65 and over (2012, n.p.). This is enough to indicate that accidental falls are a significant problem -- but the question here is what, if anything, can be done to address the problem. On the one hand, accidental falls should ostensibly be a preventable condition, despite the fact that the CDC, as noted earlier, has testified to the reluctance of many older adults to admit the problem to a medical care provider.

If we focus on a specific population -- adults 65 and over with a cardiac medical problem -- we can observe that accidental falls can be the cause of injury ranging from the moderate to the life-threatening, and are associated with increased risk of early death (CDC 2012, n.p.) Focusing on the 65 and older cardiac medical problems, the existing literature on the subject of accidental falls can give a relatively good sense of the population in question, including their medical background and the causes and results of the accidental falls themselves. According to the 2011 fall-related injury report from Barnes Jewish hospital, a total of 1165 accidental falls were recorded during that year in the hospital. Of the falls in that year, 962 of the patients involved sustained no injuries; 159 sustained minor injuries; 24 sustained moderate injuries; and 20 cases resulted in major injuries or death. 22% of the accidental falls were sustained by patients between 66 and 75 years old. In terms of causes related to the accidents, related to environmental issues within the hospital itself, rolling equipment (e.g., IV poles, bedside tables) accounted for 35% of the incidents, inappropriate footwear accounted for 22%, a necessary item being placed out of the patient's reach was the casue in 21% of incidents, slippery floors were involved in 12% of incidents, and finally trip-hazards or clutter were implicated in 9% of the accidental falls. Temporally, the breakdown for falls during shifts was 31% occurring during the day, 36% during the evening, and 33% at night. A 2005 study of the same hospital, conducted by Krauss et al., incidated that overall 30% of hospital patient accidental falls resulted in injury -- 4 to 6% of those accidental falls resulted in injury that was deemend serious (p.117). Hitcho et al. conducted a similar study at Barnest Jewish Hospital in Saint Louis, and concluded that accidental falls occurred at a rate roughly between 2.3 to 7 accidental falls per 1000 patient-days spent in the hospital (Hitcho p.734). These rates are high enough to be a concern to hospital administrators, both for reasons of the possibility of significant injury, but also for reasons related to hospital quality (with increased cost being the most significant). Hitcho et al. (2004) noted that those patients who are actually injured due to an accidental fall end up having additional health care costs, with an average increased amount recorded of $4,200 (p.732). The significance of this increased need for health care related to accidental falls that occur within…