The Joint Commission, the oldest and largest healthcare accrediting organization in the United States, tracks sentinel events—patient safety events that result in death, permanent harm, or severe temporary harm. Despite also being called never events, the most recent data show that sentinel events are actually on an upswing.
From 2020 to 2021, the total number of reported sentinel events nationwide skyrocketed by nearly 50%. As a former hospital administrator who served on hospital committees monitoring quality improvement, this really got my attention. When I dug into the details, though, it made sense.
The category of sentinel events with the largest increase was patient falls, which shot up by a jaw-dropping 2.8 times in the year-to-year comparison.
Patient falls are serious business. They’re certainly sentinel/never events, yet they continue to happen. When they do, they cause significant patient injuries, including broken bones and head trauma, and require expensive surgical and hospital care.
It’s always a shame when a patient goes to a hospital for care and treatment, and they end up with a new hospital-acquired injury. Falls are in that category of health care-acquired injuries.
The standard of care requires hospital nursing staff and physicians to perform a comprehensive fall risk assessment on every patient who’s treated in the emergency room (ER) or admitted to a hospital unit.
Although hospitals may use any of the various standardized fall risk assessment tools that are available in the market, the standard of care requires physicians, nurses, and providers to consider each patient’s individualized fall risk. That means evaluating factors including:
• History of prior falls
• Medical history, including presence of neurologic conditions (prior stroke, for example), cognitive issues (things like dementia or Alzheimer’s disease), or diabetes (possible peripheral neuropathy)
• Cardiac conditions
• Medications that might cause dizziness or unsteady gait
Here at Painter Law Firm, we’ve seen an increase in calls from potential clients about serious patient injuries from falls. We’ve noticed a correlation between the number of patient falls and those hospitals who’ve frowned upon or outright banned patients from having a family member or friend with them while they’re at the hospital.
Any time a patient fall occurs, the nursing and medical staff are required to document the fall, assess any patient injuries, and provide appropriate diagnostic and medical care. In many claims, we’ve seen a surprising lack of documentation.
One of our pending medical malpractice cases involving a hospital in The Woodlands, Texas immediately comes to mind. Our client is a man in his 70s. Let’s call him Danny.
Danny went to the hospital ER with complaints of back pain. His wife was turned away at the door because the hospital had a policy against allowing non-patients into the facility.
Danny had been previously diagnosed with peripheral neuropathy from diabetes and early dementia. He shared that information with the triage nurse. She asked about his medication history, and Danny told the nurse that he was taking Flexeril (a muscle relaxer) and Tylenol 3 (a narcotic pain medication). The nurse took his vital signs and noted that his blood pressure was abnormally low.
All of these are factors that should’ve triggered the triage nurse to recognize that Danny had an increased fall risk. Yet, the nurse noted that he was a low fall risk and sent him to the bathroom unassisted for a urine sample. Unfortunately, Danny did not make it to the bathroom. He fell in the hallway and broke his hip. I have no doubt that this fall wouldn’t have occurred if Danny’s wife had been allowed to stay with him in the ER.
After the fall, the ER nursing staff and physician didn’t document any report or assessment. Danny was ultimately admitted to the hospital, where he faced a painful hip surgery.
Based on our review of the case with medical and nursing experts, we believe Danny’s fall would have been entirely avoided if the triage nurse had appropriately assessed fall risk, which would have led to implementation of individualized fall preventions, including assistance to the bathroom. This is extra important for hospitals, such as this one, that refused to allow patients to bring a loved one or friend with them for help.
If you’ve been seriously injured because of poor hospital, nursing, or medical care in Texas, then contact a top-rated, experienced Texas medical malpractice lawyer for a free consultation about your potential case.
