Falls Reported as Serious and Sentinel Events

Matthew Pitt, Senior Adviser, Reportable Events HQSC Presentation 3 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC

The 50% Rule• From 2007/08 increased by 50% each year to

high of 195 in 2010/11

• Falls approx 50% of all SSEs

• Fractured neck of femurs involved in approx 50% of Falls SSEs

The past• Until 2011/12, no routine reporting of SSEs to

Ministry/Commission, thus no feedback loop to DHBs that encouraged reporting and resolved variation

• Variation in reporting of falls as SSEs by DHBs (the “Preventability Factor”)

• DHB systems did not always record ‘harm’, thus on querying DHB systems for “Falls with harm”, some events fell through cracks.

• Were falls increasing, was reporting improving, or both?

Falls SSEs - 07/08 to 11/12

Fractured neck of femur

#NOFs as % of all SSE falls

Unscientific study• Of Falls SSEs reported in 2011/12, 27 had a

completed review• Of these 27:– 7 (26%) reviews indicated that there was a preventable

element to the fall (no risk assessment; supervision could have been better; etc).

– 20 (74%) reviews state either explicitly – or implicitly through no recommended changes – that the fall was unpreventable.

“Patient [was] independent with mobilising and self caring … He had not done the drawstring up on his track pants when he tried to stand up to go to the toilet. The pants fell down causing the patient to trip.”“[Patient] had been mobilising with walking frame during admission. Prior to fall had been assessed and cleared for discharge by physiotherapist and medical team.”

“Patient under nurse supervision due to falls risk. Nurse waited in patient’s room after instructing the patient to ring call bell prior to getting up from toilet. Patient had complied with this request three times that morning.Patient fell when attempting to mobilise without having called for assistance.”“Fully independent patient fell, fracturing clavicle. … No cause for fall identified.”

A personal request• Don’t say that all falls are preventable, as you

will lose your audience: bedside staff.

• Do say that all falls should be assumed to have been preventable until a review has told you otherwise.

Addendum 1: Fall harm SSE 11/12

Addendum 2: Falls SSEs 09/10 to 11/12