Falls and Patient Safety

Challenges to face

Falls are the most common cause of injuries among elderly people and happens to both home living and institutionalized. Fall risk increases with age, and incidence is particularly high in those above 80 years.

Injuries caused by falls leads to suffering and reduced quality of life, and may result in everything from bruises to fractures and even death. Fear of new falls, immobility and need of health care support are other consequences. Falls also have socioeconomic consequences: Hip fractures are a frequent fall injury among elderly, and constitutes the most common cause of hospitalization in surgical orthopaedic wards in Norway. Many will need long-term care, creating more demand for municipal health care services. 

Several factors may increase the risk of falling, and the most significant are: high age, previous falls, impaired sensation and perception, physical disability, and dependency in activities in daily living (including use of aids). There are different conclusions regarding associations between falls and medical diagnoses, fair of falling, and drug use.

Effects and experiences of interventions

Among single interventions showing fall-reducing effect, we found physical training (including several components), and supplements of vitamin D (if the level initially is low). It is uncertain whether environmental interventions, medication reviews, and education can reduce the number of falls. However, education may contribute to increased professional awareness and knowledge-based practice among health providers, and environmental interventions may enhance patients’ quality of life caused by increased safety and social benefits. Screening tools can be a supplement to professional discretion during fall risk assessments.

When it comes to multifactorial interventions (i.e. fixed combination of two or more interventions), there are different conclusions regarding effect on incidence of falls, fall risk, and fall related injuries. Development projects report mainly positive experiences; municipality projects involving several actors (interdisciplinary and interdepartmental, volunteers), including locally adopted interventions, seems to increase knowledge and professional awareness on fall prevention – both among the elderly, the management, and the employees. Fall registration and physical activities combined with social activities and preventive home visits to the elderly, are reported to be the most effective interventions.

So far, there is a lack of publications describing the municipalities’ experience of implementation of the Norwegian Patient Safety Programme’s target area “Prevention of falls”. The existing publications show inconclusive and uncertain results, where both increased and reduced number of falls are reported. Overall, participation in collaborative network is experienced as useful and educational, where awareness raising in the staff group, sharing experiences and ideas, and interdisciplinary collaboration, are highlighted as positive effects. Factors for success include: common routines, agreed conceptual understandings, interdisciplinary collaboration, inform and engage employees by using blackboards for fall registration, and sufficient period of time to measure long term effect of the interventions.

Working with fall prevention require both knowledge about the problem area and ability to cooperate. Studies show that health professionals may overlook the reasons for why elderly fall. Despite they report high awareness on patient safety, it seem like they take action first when there has been an accident. To respect the patient’s integrity and autonomy, and at the same time, prevent him from falling, may be ethically challenging. The patients themselves can have other opinions of fall risk and possible approaches. In order to succeed with fall prevention, it is therefore important to identify the patients’ individual experiences and attitudes.

Need for more knowledge

• studies measuring outcomes of individualized interventions tailored to prevent falls in homebound elderly and nursing home residents 
• studies with multifactorial interventions aimed at preventing falls in nursing home residents
• intervention studies with longitudinal design, both in home health nursing care and in nursing homes
• research and development projects reporting the municipalities’ experiences from the Norwegian Patient Safety Programme’s target area “Prevention of falls” – over the long term
• studies looking at welfare technology used in fall prevention, and including larger samples of both homebound elderly and nursing home residents