Preoperative pediatric patient falls are considered an important and costly problem in the United States healthcare system. It leads to lacerations, internal bleeding, consequently leading to increased health care utilization, critical morbidity, mortality, and prolonged periods of staying in the hospital. Children, as well as elder people, are defined as vulnerable patients. Therefore, they need special attention in order to organize appropriate acute care services, such as collaborative techniques discussed by Kingston, Bryant, and Speer (2010). This paper summarizes and synthesizes the information about inpatient falls prevention. It divides preoperative patient falls into physical, physiologically expected, physiologically unexpected, responding to treatment, developmental, horseplay, or accidental categories. It shows the genesis of preventive approach starting from the National Patient Safety Goal Agency’s standard model investigation, including the approach, which is based on considering every child to be in a risk group, but not predicting an exact group that needs prevention.
In the United States, falls are recognized to be the leading cause of nonfatal injuries occurring in healthcare practice. The children from birth to 19 years old were registered to have more than 2 million calls per year, and therefore a pediatric patient fall is defined as a safety concern. Patient fall is defined as any unexpected descent to the floor of a hospitalized patient with or without injury. It is considered to be a medical error the solution for which should be regulated both by healthcare quality and regulatory decisions. A patient fall may be characterized as an unplanned plummet of the carpet with or without the damage of the patient. Annually around 700 thousand – 1 million people in the United States fall in the hospitals. It was observed that from 1.3 to 8.9 per 1000 occupied beds experience patient falls in the hospitals of the United States. Falls in preoperative pediatric patients may result in fractures, lacerations, internal bleeding, causing prolonged health care, critical morbidity, mortality, and a long period of stay in the hospital. Nonetheless, falls among pediatric inpatients are still poorly researched.
Most often identified cases of patient fall occur among elderly patients. The main reasons for their falls are the lack of staff communication, space orientation, and training; improper patient assessment; physical environment and care planning. Research shows that almost one-third of falls can be prevented. According to the Centers for Medicare & Medicaid Services, since 2008 certain types of traumatic injuries are not reimbursed by the clinics. Moreover, many consequences occur after the actual fall. Therefore, prevention of falls becomes the hospitals’ first priority. Therefore, the medical staff is supposed to address the issue, keep the patient safe, and bring about the recuperation of physical and mental capacity. However, it is hard for doctors and nurses to distribute their attention to direct hospital services and fall prevention equally. Up to 2010, only one initiative focused on fall prevention programs and risk evaluation existed. In 2005, a National Patient Safety Goal agency was founded. It aimed to spread fall prevention programs among the hospitals. The standard approach for pediatric fall prevention was to consider all the children at risk of falling. The proportion of patients per nurse was about 3-4 to 1. Moreover, this model included 24-hour supervision. Although the model was evaluated as effective, the lack of risk of falling was the weak side of the approach.
According to the Joint Commission, patient falls are considered to be one of the top five essential events. Janice Morse’s analysis shows that approximately 14% of all falls in clinics are accidental, another 8% are unanticipated, and 78% are anticipated falls. Pediatric patient falls are divided on the basis of physical, physiologically expected, physiologically unexpected, response to treatment, developmental, horseplay, or accidental categories. Most hospitals use the classification developed through the algorithms by the National Coordinating Council for Medication Error Reporting and Prevention based on two levels of medical error: 1) the capacity to cause an error and 2) an occurred error. According to this algorithm, the harm is defined as an impairment of the physical, emotional, or psychological function or structure of the body and/or pain resulting therefrom.
Fall prevention includes managing patient-related risks such as walking, side effects, confusion, or frequent toilet needs. This monitoring practice was considered to reduce the number of falls, though it was never systematically organized in each hospital. In order to achieve success, an interdisciplinary approach has to be implemented. It includes routine hospital staff’s obligations combined with each patient’s specific risk profile. It is necessary to admit that many cases are caused by the lack of close supervision of the hospital staff. Consequently, a nurse’s availability and attitude are vital. Observational studies prove the existence of a correlation between the level of competency and the number of fall incidents. For example, fall rates are lower at night. As a result, it may be caused by the reduction of patient’s and nurse’s activity.
It is hard to predict whether a patient has a low or high-risk profile. As most patients do not fall while they are in the clinic, this issue is interesting for the risk management study, as well as for the nurses’ skills improvement. The limitation of this research question is in the difference between risk factors that are observed in order to correct and improve the situation, and those which are observed for the purpose of prediction. However, current pediatric attempts to measure children’s risk for falls are based on the scores from fall risk assessment tools. Conducted in 2009 research investigated the most valid measures of assessment in children. It lasted for over 6 months and attracted 26 children’s hospitals. Therefore, 770 pediatric falls were found. Among these cases, from 6% to 60% initially were described as a “low-risk group”. On the basis of another research, which included 400 cases during 8 years, it was hypothesized that falls were the result of human, environmental, biomechanical, and system factors. As an exception, a quick reaction may help a patient succeed in avoiding the fall. Unfortunately, standard fall prevention cannot include solutions for momentary cases.
Prevention of hospital falls is one of the most important steps to creating appropriate care services. A safe environment is the first factor that needs control in order to avoid falls that may result in injuries leading to hospitalization, complications, and damage to the hospital’s reputation. Moreover, the example of Magnet Children’s hospitals has to be mentioned. This hospital has tried to develop valid pediatric screening tools and benchmarks for inpatient pediatric falls. Regular classification developed by Morse, Tylko, and Dixon in 1987 were supplemented with the child growth development category. It has shown that pediatric falls could use a general scheme.
The current approach of defining children who belong to the high-risk group is based on the primary demographic and clinical characteristics of children. However, pre-operational pediatric patients continue to fall, and thus a new method has to be proposed. In 2013, a new paradigm of the minimization of pediatric patient falls and injuries were developed. Interdisciplinary Momentary Confluence of Events Model was based on already existing factors contributing to falls and injuries, and it was complemented by a new one. Five of seven components in this approach are similar to the Joint Commission’s patient safety event taxonomy. Biomechanical and human factors were added to the already existing factors. As a result, Interdisciplinary Momentary Confluence of Events Model consisted of child human factors, environmental human factors, biomechanical factors, caregiver human factors, parent human factors, and system factors. The approach suggests not to predict a group, which needs prevention but to consider all patients to be at risk of falling. It is recommended to develop a new pediatric patient falls taxonomy by considering 6 proposed criteria and reporting missed falls as adverse events.
Pediatric pre-operational patients, including elders above 65 years old, are considered to be vulnerable patients. In order to manage this group effectively, there are five steps to be followed. Firstly, the vulnerability of the patient should be identified. Secondly, a patient program should be implemented. Thirdly, frequent assessments must be conducted. Then, specific therapy is recommended. Lastly, the nursing staff should always remember to provide supportive care.
Preoperative pediatric patient fall is considered an issue which needs to be addressed, since it causes lacerations, internal bleeding, increased health care needs, critical morbidity, mortality, and prolonged periods of stay in the hospitals. Children, as well as elder people, are defined as vulnerable patients, and thus they require special care. Pediatric patient falls fall into physical, physiologically expected, physiologically unexpected, response to treatment, developmental, horseplay, or accidental categories. The standard approach to pediatric falls prevention includes considering all children to be at risk of falling. In order to cure the medical error, most hospitals use a classification based on the capacity to cause an error and an already occurred error. Many fallen patient cases are caused by the lack of close supervision of hospital staff. It is hard to predict the risk profile of each patient. However, a safe environment is the first factor that requires control in order to avoid falls and their consequences.