Becker's Clinical Quality & Infection Control

17 PATIENT & CAREGIVER EXPERIENCE How hospitals can prevent the most common sentinel event By Ashleigh Hollowell F alls are the most common sentinel event resulting in harm or death of hospital patients so far in 2023, according to data from e Joint Commission. Between Jan. 1 through June 30, the organization recorded 720 sentinel events — 47 percent of which were falls. Patient safety experts at hospitals nationwide shared their insight into reducing falls with Becker's. Editor's note: Responses have been lightly edited for clarity and length. Nancy Foster, Vice President for Quality and Patient Safety Policy at the American Hospital Association: Preventing falls is an aim to which all hospitals are committed, but there is not a single answer to how to prevent them. Aer examining the root causes of many falls, hospitals have identified that many falls happen when patients get off of bed to use the restroom or do some other small task, not realizing that their disease, the medications they are on, or the procedure they had might have made them weaker or more light-headed than normal. To reduce the risk of this occurring, hospitals work with the nursing staff to talk to patients and their families about the risk and urge them to call a staff member if they need to get out of bed, use bed alarms that alert nurses when patients shi in their beds to get in a position that would allow them to stand, have a staff member do frequent rounding to assist patients to the restroom and other such measures. Susan Brown, PhD, RN, Chief Nursing Officer and Senior Vice President of Patient Care Services at City of Hope in Duarte, Calif.: Patients tend to get out of bed and risk falling when clinical staff can't get into the room quickly enough. e single and really the simplest thing that any health care system can do to prevent patient falls is to hard-wire staff to do purposeful, hourly rounding. Purposeful rounding means asking if the patient might need any of the four P's addressed: potty, pain, position and proximity of 'stuff.' Purposeful hourly rounding can help staff anticipate patient needs, decreasing the need to respond — maybe less timely than preferred by patients — to a call light. If patients have what they need within reach and if they are regularly offered the opportunity to go to the restroom, they are less likely to get out of bed without assistance and fall. Sonja Rosen, MD, Medical Director of Geriatrics at Cedars-Sinai in Los Angeles: While most falls are not avoidable, there are things that we can implement to help reduce risk of falling as well as injury related to falls. Identifying that patients are a risk for falls is paramount. ere are hospital policies and procedures for [the] degree of fall risk, and these must then be implemented as appropriate. e efforts to reduce fall and injury risk are multifactorial. One that can be overlooked by physicians is minimizing use of medications that can further increase risk of falls such as benzodiazepines or anticholinergic medications. n Viewpoint: The risks of patient codes of conduct By Mackenzie Bean M ore hospitals are turning to patient codes of conducts to protect healthcare workers amid a rise in rude and violent behavior. However, banning patients — especially those with behavioral health needs — who don't exhibit physical threats can pose a care quality concern, Lisa Morrise wrote in a Sept. 12 blog post for the Institute for Healthcare Improvement. Ms. Morrise serves as executive director of Consumers Advancing Patient Safety. She detailed a recent healthcare experience involving her 30-year-old son Skyler Morrise, who has schizoaffective disorder. Mr. Morrise was dismissed from his health system after a disagreement with the mental healthcare clinic's administrative manager about which provider he would see. In a letter to Ms. Morrise, the system said her son was being dismissed due to "disruptive and threatening behavior toward staff." Ms. Morrise claims the system did not offer a way to appeal the dismissal and denied her son access to his medical records, requiring him to find all new providers and delaying his treatment. While healthcare staff should be protected from patients who pose physical threats, the process for dismissing patients should involve written warnings and behavior plans for nonviolent patients, especially in behavioral health settings, Ms. Morrise wrote. Patients should also not be penalized for complaining about the care they receive, she argued. "Dismissing patients who complain is a quality and safety concern," Ms. Morrise said. "Complaints can help identify areas that need improvement. Patient insights support quality and governance initiatives. There should be no room for using dismissal as retribution for complaints." n need to be addressed. A new narrative about healthy aging is also needed, Dr. Chokshi said. "Older Americans already contribute to society through working, caring for grandchildren, volunteering and civic participation," he wrote. "Social infrastructure could be further adapted around older age as a latent natural resource, waiting for us to tap it in ways that build purpose and connection. Schools could host youth mentoring programs. Employers could create additional part-time or flexible work opportunities. Even smaller campaigns that combat ageist stereotypes, like reimagining birthday cards to ditch denigrating jokes in favor of celebratory pride, could change these narratives." n

• Cover