Elderly patients with dementia face certain risks when treated in a long term care (LTC) facility. The most common risks to patient safety for this patient population are injuries and deaths related to falls, which are about 75% preventable according to experts, result in excess of $170 billion annually, and create 15% of the re-hospitalizations which occur within a month after discharge (Currie, 2008). Thus, addressing the problem of falls in elderly patients with dementia would improve the longevity of LTC residents, reduce the burden of care on families and the healthcare system, and save large sums of money annually on re-hospitalization costs.
The Joint Commission publishes the National Patient Safety Goals every 2 years on a variety of healthcare settings, with the goal of improving patient safety through focusing on solutions to problems in healthcare delivery. The 2014 National Patient Safety Goals for LTC facilities are listed generally as follows: identify residents correctly, use medicines safely, prevent infection via proper hand hygiene, use best practices in preventing central line infections, prevent residents from falling, and prevent bed sores (www.jointcommission.org). While all of these goals are important, dementia is a significant factor in falls among the elderly and can be mitigated through the use of best practices (Varkey, 2010, p. 57).
Systems Errors and Human Factors
In recent years, the fall rate among the elderly in LTC settings has increased 40% with a high proportion of this increase among the mentally compromised. Additionally, up to 55% of falls are associated with an injury, underscoring the need for identifying systems errors or human factors which have contributed to this rise. Patient health conditions are known to be contributing factors, but other factors include environmental hazards, toileting problems, certain medications, altered mental states, poor footwear choices, reckless wheelchair use, and inability to adapt to a changing environment (Currie, 2008).
Medical errors can be broken down into both human and system errors. While human errors are attributed to cognitive failures, they do not occur in isolation because a well-designed system would prevent a human error from occurring via the use of safety checks. Therefore, most medical errors are really rooted in poor system design which allow errors to occur (Galt & Paschal, 2011, p.109).
An estimated 78% of falls can be anticipated in LTC residents, and therefore can be prevented (Currie, 2008). Like other medical errors, the high rate of falls occurs because of poor awareness and understanding of the causes, and the failure to address these causes is due to inherent traits in the medical culture, which traditionally has not been patient-centered (Galt & Paschal, 2011, p.109).
Strategies and Tools to Reduce Fall Risk
Happily, resources are available to assist LTC facilities in reducing the fall rate amongst their residents, such as the long-term care minimum data set (LTCMDS) which documents the susceptibility to and history of falls in LTC residents. Another tool is the Nursing Home Quality Initiative, which offers a more sophisticated measure of the probability of fall risk in LTC residents because it tracks both physical and cognitive decline over time.
Additionally, exercise programs have been shown to be helpful in reducing the rate of falls, along with improved nutrition, corrected eyesight, regular fall assessments and cardiac pacing. Handrails, secured rugs, stair tread tape, and thin-soled shoes are effective environmental strategies (Curries, 2008), In their publications Check for Safety: A Home Fall Prevention Checklist for Older Adults and What You can Do to Prevent Falls, the CDC recommends many of the same preventive measure for patients and families as those used in LTC facilities, demonstrating that fall prevention in the elderly is achievable with relatively simple steps.
However, the CDC recommends a multidisciplinary team approach which espouses the above practices (cdc.gov). When designing systems, LTC facilities should plan for human error in order to develop effective safety checks similar to those used in high reliability organizations (HROs). This requires understanding the conditions in which healthcare workers provide care, and the ways in which they assimilate and communicate information (Jenks & Gelinas, 2010). Future research and strategies into fall prevention are likely to improve this problem.
References:
2014 Long Term Care Medicare/Medicaid Certification-based Option
National Patient Safety Goals, (2014). The Joint Commission. Retrieved from:
Click to access 2014_LTC2_NPSG_E.pdf
Currie, L. (2008 April). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Section III: Patient-Centered Care. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US). Chapter 10 “Fall and Injury Prevention”. Retrieved from:
Falls in Nursing Homes, (2012, February). The Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html#prevent
Galt, K. A., & Paschal, K. A. (2011). Foundations in patient safety for health professionals. Sudbury, MA: Jones & Bartlett.
Jenks, S. & Gelinas, L., (2010). Laureate Education, Inc. (Executive Producer). Quality assessment and improvement. Baltimore: Author. “Patient Safety”.
Improving Patient Safety in Nursing Homes: A Resource List for Users of the AHRQ Nursing Home Survey on Patient Safety Culture, (2010, June). Agency for Healthcare Research and Quality, Publication No. 11-0012-1-EF. Retrieved from:
http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/nursing- home/resources/nhimpptsaf.pdf
Varkey, P. (2010). Medical quality management: Theory and practice. Sudbury, MA: Jones & Bartlett.
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