Why Do Patients in Acute Care Hospitals Fall? Can Falls Be Prevented?

Patient falls are serious problems in acute care hospitals and are used as a standard metric of nursing care quality.1 The unfamiliar environment, acute illness, surgery, bed rest, medications, treatments, and the placement of various tubes and catheters are common challenges that place patients at risk of falling. Falls are devastating to patients, family members, and providers. A single fall may result in a fear of falling that can begin a downward spiral of reduced mobility, leading to loss of function and further falls.2-4 There have been many published research studies regarding falls. Although there is a sense of urgency in hospitals to prevent falls to “do no harm” and because Medicare will not reimburse hospitalization costs due to fall related injuries,5 patient falls remain a serious problem in US hospitals. A review of fall prevention literature was conducted of English-language publications found in MEDLINE (1966 to November 2008) and CINAHL (1982 to November 2008) databases following procedures suggested by a literature consult service6 and using the search terms accidental falls, qualitative research, risk assessment, accident prevention, nurses, nursing assistants, and hospitals. Abundant research on fall risk assessment has resulted in well-established fall risk factors,7-10 but assessment does not prevent falls; interventions are needed to prevent falls. Regrettably, the evidence regarding the effectiveness of fall prevention programs is inconclusive.11 Synthesis revealed that this may be the result of many barriers to studying fall prevention in hospitals. Designing experiments to study fall prevention is challenging3,10,12 because randomized controlled trials cannot be performed because once risk status is established, it is unethical to withhold measures to prevent falls, that is, to place the patient in a no-treatment/control group. It is also unclear if patients are exposed to an intervention and do not fall, if they were at risk for falling in the first place, or whether the application of a fall prevention intervention in fact prevented a fall. Studies conducted using multifaceted interventions with unknown strength or fidelity have ambiguous findings, further complicating the literature. As a result of this dearth of evidence, qualitative studies related to fall prevention in hospitals were reviewed. Yet, few qualitative studies have been conducted with hospital-based registered nurses (RNs) and nursing assistants (NAs), the direct care providers at patients’ bedsides. A comparison of views among healthcare providers, seniors (aged ≥65 years for whom falling is a common and comorbid condition),13 and researchers regarding reasons for falling revealed that providers and seniors focused on antecedents and consequences of falls, whereas researchers focused on the actual fall itself.14 An exploration of the views of NAs revealed that NAs felt their views were often peripheral to the administrative and educational processes related to fall prevention. Furthermore, NAs believed that falls were not preventable.15 All bedside providers should be brought into the fall prevention process,15 as should patients and their families.16 Several summary review and meta-analysis articles3,12,17 concluded that there is no established linkage from a patient’s fall risk assessment to communicating risk and to identifying and communicating tailored interventions to prevent falls. Although the primary data in those articles are up to a decade old, we found no recent research articles about connecting risk assessment to tailored fall prevention interventions, which limits the ability of bedside RNs and NAs to prevent patient falls. We did find a program evaluation that reported a modest decrease in falls after introduction of a tailored fall prevention program, but the results were not significant.18 It is known that interventions to prevent patients from falling do not rely on highly technical, scarce, or expensive equipment. Yet, falls remain serious problems in hospitals. We sought to learn the views of RNs and NAs about why patients in acute care hospitals fall and how falls could be prevented.