Preventing falls and fall injuries in hospital: a major risk management challenge

Accidental falls are the commonest patient safety incident in hospital and are especially common in older patients. They are associated with physical and psychological harm, functional impairment, prolonged hospital stay, cost and opportunity cost. Falls often cause concern and anger from patients' relatives, are a frequent cause of complaints and inquests, and may lead to claims in clinical negligence - albeit that the financial risk from these claims is low. As such, falls and related injuries should be a major concern in risk management and governance for institutions. In reality, falls are often a marker of patients' underlying medical illness and frailty and their occurrence does not necessarily mean that there has been a failure in the duty of care or that anyone or any system is to blame. Falls rates are also dependent on the case-mix and frailty of patients on the unit, so that crude unadjusted comparison of falls rates should not be used in isolation as an indicator of care quality. Nonetheless, there appear to be large variations in falls rates. It may be that some falls are essentially inevitable or unpreventable, but that others are avoidable and unacceptable, especially as we must balance falls prevention against the duty to promote rehabilitation, respect patients' autonomy and avoid an excessively custodial, ageist or risk-averse approach to care. Even though all parties may feel that 'something should be done' to manage the risk, it is not always clear what the interventions should be. This in turn means that institutions may implement interventions or assessments which are neither effective nor evidence-based. The starting point for falls prevention programmes should always be a critical review of such evidence. In this review, we discuss the underlying causes of falls, the potential for learning from incident reporting and claims analysis and, in particular, the academic literature on falls risk assessment tools (for which the evidence base is limited) and on falls prevention interventions. Evidence from clinical trials has shown that it is possible to produce modest reductions in falls rates (if not the number of 'fallers') from whole systems interventions which incorporate a variety of approaches to falls prevention. These interventions are described in detail as well as the limitations of performing research in such a frail and unstable patient group.