Cite as National Patient Safety Agency 2010 Slips trips and falls data update NPSA: London Available from www.nrls.npsa.nhs.uk 1
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This incident is an example of the complex nature of falls, from simple trips to faints/collapses 3
NOTE: Whilst the vast majority of the falls described above are falls with healthcare units, these figures will also include a small number of falls that occurred outside healthcare premises but whilst the patient was under the supervision of healthcare staff, for example a fall that occurs during an outing from a unit caring for people with learning disabilities. bl Whilst hl not technically a patient safety incident, staff may also on occasion report as a fall an event outside healthcare control, for example a community nurse arriving on a home visit and finding the patient is on the floor after a fall. 4
NPSA definitions of severity in the context of slips trips and falls are: No harm Low harm harm requiring ii first aid id level ltreatment, t t or extra observation only (e.g. bruises, grazes) Moderate harm harm requiring hospital treatment or a prolonged length of stay but from which a full recovery is expected (e.g. fractured clavicle, laceration requiring suturing) Severe harm harm causing permanent disability (e.g. brain injury, hip fractures where the patient is unlikely to regain their former level of independence) Death where death is directly attributable to the fall 5
Death figures have been clinically reviewed and obvious coding errors and those incidents that clearly indicate death from natural causes rather than as a result of a fall have been excluded. However, it should be noted reporting usually occurs soon after the fall and so reports do not include late mortality known to be associated with hip fracture. Other severities are as stated by the original reporter. When 2005/06 data were used for the publication of Slips trips an d falls in hospital, only around 50% of NHS organisations in England and Wales were reporting to the NRLS at least monthly; by 2009 over 95% of NHS organisations in England and Wales were reporting to the NRLS at least monthly. This is likely to lead to the identification of higher numbers of falls. 6
Search strategies have been improved and the number of regularly reporting trusts have increased since the publication of Slips trips and falls in hospital, both of which are likely to lead to the identification of higher numbers of fractures than in 2005/06 incidents. Possible fractures were identified for review by use of any of the following terms in free text: fracture (removed 'no' or 'not' preceding) # (removed 'no' or 'not' preceding) orth* NOF #NOF PFF #PFF femur short* and rotated (removed 'no' or 'not' preceding) (bone or hip) and (broke or break (removed 'no' or 'not' preceding)) All severe harm incidents and incidents reported as resulting in death were reviewed to identify reports describing clinical or radiological diagnosis of fracture, as was a random sample of 500 moderate harm incidents drawn from a pool of 1520 incidents ; confidence intervals relate to extrapolations from this sample. Low harm and no harm incidents were not reviewed since fractures should be reported as causing at least moderate harm. Some patients experienced more than one fracture in a single fall; in these cases the most serious fracture was counted. 7
Possible fractures were identified by use of any of the following terms in free text: fracture (removed 'no' or 'not' preceding) # (removed 'no' or 'not' preceding) orth* NOF #NOFPFF #PFFfemur short* and rotated (removed 'no' or 'not' preceding) (bone or hip) and (broke or break (removed 'no' or 'not' preceding)) All severe harm incidents and incidents reported as resulting in death were reviewed to identify reports describing clinical or radiological diagnosis of fracture, as was a random sample of 500 moderate harm incidents drawn from a pool of 1520 incidents. Low harm and no harm incidents were not reviewed since fractures should be reported as causing at least moderate harm. Some patients experienced more than one fracture in a single fall; in these cases the most serious fracture was counted. 8
Possible brain injuries caused in falls were identified by clinical review of incidents with any of the following terms in free text of slips trips and falls reported as resulting in death, severe harm, or moderate harm: 1) sub dural 2) CT 3) MRI 4) neuro (exclude obs.) 5) unconscious 6) unrespon 7) cere 8) skull 9) glasgow coma score, gcs (exc gcs 15) 9
The differing proportions of harm from different care settings may reflect differences in reporting culture or in their inpatient population. Higher proportions of injurious falls in mental health units and community hospitals are plausibly related to patients with dementia unable to react as quickly to save themselves from injury, and the older age profile fl of community hospital patients which hleaves them more vulnerable to soft tissue injury and fractures. 10
Age or age band was provided for79.6% of reported falls. Of falls where age or age band was provided, 82.2% occurred in patients aged over 65 years (65 100+ years), 67.6% in patients aged over 75 years (75 100+ years), and 34.0% in patients aged over 85 years (85 100+ years). This pattern shows little change since the original 2005/06 data. Relative to bed bdoccupancy, patients over 85 years are at the highest h risk of falls; fll the chart tails off after this age because the age profile of the population means there are fewer hospital beds occupied by patients at very advanced age, not because the very old are at lower risk of falling. 11
This pattern shows little change from 2005/06 data. Time of falls is likely to be affected by patient activity (e.g. washing and dressing is usually done in the morning), staff activity (e.g. physiotherapy is usually provided during office hours), time when visitors are at the bedside, patient physiology (e.g. postural drops in blood pressure are more lk likely l to occur on first rising from bed) bd) and the effects of medication on awareness and mobility (e.g. sleeping tablets). 12
Mean rate = 5.6 falls per 1,000 bed days. These benchmarks have been provided because of requests from the NHS, but comparison between organisations may not be particularly helpful for falls prevention; the NPSA would encourage organisations to focus more on improvement over time within their own organisation than on whether their fall rates are higher or lower than in similar organisations see the Patient Safety First How to Guide for Reducing harm from falls and Slips trips and falls in hospital for more information on this. Organisations with very low rates may indicate a poor culture of reporting falls rather than robust prevention of falls. Falls rates will be expected to vary between organisations due to: differences in the local population (e.g. hospitals serving towns which are popular retirement spots may have higher rates than hospitals serving a younger inner city population) differences in specialist services (e.g. services focused on rehabilitation or people with dementia are likely to see higher rates) reporting culture (i.e. how consistently falls, especially no harm falls, are reported) The effect of different falls prevention practices may be overshadowed by these differences in the vulnerability of the inpatient population to falls and in reporting culture. These data show less variation between extremes than the 2005/06 data; this is likely to reflect more consistent reporting of falls at a local level, and the mean rate of 5.6 falls per 1,000 bed days is more likely to be accurate than the 2005/06 rate which was affected by a number of organisations reporting implausibly low numbers of falls. 13
Mean rate = 3.8 falls per 1,00 bed days. These benchmarks have been provided because of requests from the NHS, but comparison between organisations may not be particularly helpful for falls prevention; the NPSA would encourage organisations to focus more on improvement over time within their own organisation than on whether their fall rates are higher or lower than in similar organisations see the Patient Safety First How to Guide for Reducing harm from falls and Slips trips and falls in hospital for more information on this. Organisations with very low rates may indicate a poor culture of reporting falls rather than robust prevention of falls. Falls rates will be expected to vary between organisations due to: differences in the local population (e.g. hospitals serving towns which are popular retirement spots may have higher rates than hospitals serving a younger inner city population) differences in specialist services (for mental health units, those with high levels of inpatient provision for people with dementia are likely to see higher rates) reporting culture (i.e. how consistently falls, especially no harm falls, are reported) The effect of different falls prevention practices may be overshadowed by these differences in the vulnerability of the inpatient population to falls and in reporting culture. In 2005/06 relatively few mental health units were regular reporters and so these 2007/08 data drawn from many more organisations are much more likely to be representative. Mental health units tend to combine a working age inpatient population with low risk of falling with services for older people with dementia who at at very high risk of falling, so rates are likely to be influenced by their balance of service provision. 14
Mean rate = 8.6 falls per 1,000 bed days, primary care organisations with inpatient beds only; this is primarily but not exclusively community hospital/intermediate care provision. These benchmarks have been provided because of requests from the NHS, but comparison between organisations may not be particularly helpful for falls prevention; the NPSA would encourage organisations to focus more on improvement over time within their own organisation than on whether their fall rates are higher or lower than in similar organisations see the Patient Safety First How to Guide for Reducing harm from falls and Slips trips and falls in hospital for more information on this. Organisations with very low rates may indicate a poor culture of reporting falls rather than robust prevention of falls. Falls rates will be expected to vary between organisations due to: differences in the local population p (e.g. hospitals serving towns which are popular p retirement spots may have higher rates than hospitals serving a younger inner city population) differences in specialist services (e.g. services focused on rehabilitation or people with dementia are likely to see higher rates) reporting culture (i.e. how consistently falls, especially no harm falls, are reported) The effect of different falls prevention practices may be overshadowed by these differences in the vulnerability of the inpatient population to falls and in reporting culture. In 2005/06 relatively few community hospitals were regular reporters and so these 2007/08 data drawn from many more organisations are much more likely to be representative. Given the much higher age profile of patients in community hospitals, a higher rate of falls than in acute hospitals would be predicted. In community hospitals the denominator of bed days is complicated by arrangements for intermediate care beds, which may be jointly funded by social services and therefore not counted as bed days in hospital episode statistics. This undercounting of bed days can lead to an artificially inflated falls rate. 15
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