Have an account? Please log in.
Text size: Small font Default font Larger font
.
Radiology Daily
Radiology Daily PracticalReviews.com Radiology Daily

Not All Patient Falls Are Predictable, Preventable

March 24, 2008
Written by: , Filed in: Practice Management
  • Comments
.

Several leadership organizations in the health care industry would like to
further explore the applicability and implications of the ‘never events’
defined by the National Quality Forum, especially regarding the issue of
patient falls.

Despite patient education and good care, patients may fall while being cared
for in a health care facility, which may result in death or serious
disability. One interesting case study of such a fall was documented by a
nurse who was caring for a patient with a cardiac history and atrial
fibrillation (A-fib). Because of the patient’s A-fib, he was receiving
anticoagulation therapy, and as a result, he had an elevated International
Normalized Ratio (INR; measure of blood clotting potential). In addition, the
patient was experiencing other kinds of arrhythmias at the same time.

The patient was taken to the cardiac catheterization lab for ablation therapy
and had some success with this treatment. In addition, new medications were
added to the patient’s treatment regimen. Because of the intensity of these
new medications, the decision was made to keep the patient in the hospital.
The health care team wanted to avoid complications from patient immobility, so
the patient was encouraged to walk and appeared to be very steady on his feet.

Then, one day, as the patient was walking down the hall, he experienced a
potentially lethal cardiac arrhythmia that caused him to lose consciousness,
and he abruptly fell down and hit his head. He experienced a fairly
significant cerebral bleed because his INR was elevated. In the end, this man
who came in to have his cardiac arrhythmias treated died in the hospital from
a bleed associated with the fall.

Was the fall for this particular case predictable or preventable? Probably
neither. Nonetheless, the fall was considered a ‘never event.’ This case and
others like it generate a lot of discussion and even some controversy. Because
of cases like this, some of our leadership organizations would like to further
explore these ‘never events’ and their implications.

Reference
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Falls
Occurring at the Health Care Facility – Part 2.

Several leadership organizations in the health care industry would like to further explore the applicability and implications of the 'never events' defined by the National Quality Forum, especially regarding the issue of patient falls. Despite patient education and good care, patients may fall while being cared for in a health care facility, which may result in death or serious disability. One interesting case study of such a fall was documented by a nurse who was caring for a patient with a cardiac history and atrial fibrillation (A-fib). Because of the patient's A-fib, he was receiving anticoagulation therapy, and as a result, he had an elevated International Normalized Ratio (INR; measure of blood clotting potential). In addition, the patient was experiencing other kinds of arrhythmias at the same time. The patient was taken to the cardiac catheterization lab for ablation therapy and had some success with this treatment. In addition, new medications were added to the patient's treatment regimen. Because of the intensity of these new medications, the decision was made to keep the patient in the hospital. The health care team wanted to avoid complications from patient immobility, so the patient was encouraged to walk and appeared to be very steady on his feet. Then, one day, as the patient was walking down the hall, he experienced a potentially lethal cardiac arrhythmia that caused him to lose consciousness, and he abruptly fell down and hit his head. He experienced a fairly significant cerebral bleed because his INR was elevated. In the end, this man who came in to have his cardiac arrhythmias treated died in the hospital from a bleed associated with the fall. Was the fall for this particular case predictable or preventable? Probably neither. Nonetheless, the fall was considered a 'never event.' This case and others like it generate a lot of discussion and even some controversy. Because of cases like this, some of our leadership organizations would like to further explore these 'never events' and their implications. Reference Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Falls Occurring at the Health Care Facility - Part 2. [text_ad]
.

Permalink: http://www.radiologydaily.com/?p=2638

Tags: , , , , , , , , , , , , ,

  • Comments
.

Would you like to keep current with radiological news and information?

Post Your Comments and Responses

Comments are closed.