Stools are a common source of falls for patients, visitors and staff. These chairs are not meant for long-term seating and are primarily used by staff. However, when left unattended, patients or their visitors will seek the vacant seat to rest or relax if all others are occupied. According to the Agency for Healthcare Research and Quality (AHRQ), between 700,000 and 1,000,000 people in the nation fall in hospitals each year. Stool falls reported in the CHPSO database were all unassisted and often led to visits to the ED for fractures or lacerations.
Hearing aids. Dentures. Eyeglasses. Wallets. Cell Phones. These are a few of the many items reported to the CHPSO database that have been misplaced, thrown out, or disappeared during a patient’s visit. Patients cannot live without these items as they help them hear the latest news on TV, eat their meal, see the news and their meal, and communicate with others. In one case, a patient had to go on a liquid diet and eat soft foods because his dentures were misplaced. Often times, these items get rolled up into a napkin and inadvertently thrown out while on a meal tray or at the bedside.
Case: A nursing mother fell asleep in the hospital bed and her newborn slipped out of her arms, falling to the floor. The mother had been on painkillers that made her drowsy. The infant was taken for a CT that showed a skull fracture. There were no family members in the patient’s room when the incident occurred.
In a preliminary search of CHPSO falls and perinatal events, approximately 35 in-hospital infant falls from 2014-2015 were due to the following:
Case:A 46-year-old substance-dependent male went to the Emergency Department for sweating, chest pain and one week of cough, and the emergency physician had a chest x-ray ordered for him. The patient was diagnosed with pneumonia and was discharged with a prescription for an antibiotic. For weeks later, the patient returned to the ED because he was coughing up blood. The clinical team completed both a tuberculosis skin test (TST) and sputum for acid-fast bacilli.
Staff reported problems with patient monitors, but the equipment worked properly when tested in the biomedical engineering department. Problem tracking found that patient monitors experienced intermittent malfunctions mostly on one particular side of one particular floor, located above a loading dock. Citizens’ band (CB) or other mobile radio transmissions from vehicles arriving at the loading dock were strongly suspected to have been the cause of the patient monitor interference. Truck drivers were asked to use house phones on arriving at the hospital, and the problems were resolved.
In the quality and patient safety world, we have a tendency to focus on the complexity of patient care within the hospital setting. However, a classic study by Forster, et al1, reminds us that there are many concerns for the complexity of care post-discharge. Nearly 20 percent of patients experience adverse events within three weeks of discharge; about 75 percent of which are preventable. Adverse drug events are the most common post-discharge complication, with hospital-acquired infections and procedural complications also causing considerable morbidity.
If you have run an Event Type summary report in our ECRI database, you have noticed that the largest category by volume is “Other” for the CHPSO aggregate. As we have been reviewing events classified as “other” we have noticed some common themes: non-team promoting behavior (physician), poor coordination of care, and delay in care related to insufficient staffing. Over the next few months, we will look closer at each of these issues.