7/23/155 Accepted for Publication in Geriatric Nursing

7/23/155 Accepted for publication in “Geriatric Nursing,” GN-D-15-00148

PATIENT FALLS IN HOSPITALS: AN INCREASING PROBLEM

By Thomas P. Weil, Ph.D.*

* President Emeritus, Bedford Health Associates, Inc., Management Consultants for Health and Hospital Services, Katonah, N.Y., and Asheville, N.C (1975-2001). Contact Info: 1400 Town Mt. Road, Asheville, N.C. 28804; 828-252-1523; FAX: 828-253-3820. [email protected] 2

ABSRACT Despite six decades of worldwide efforts that include publishing virtually hundreds of related epidemiological-type studies, there has been an increase (estimated to be 46% per 1,000 patient days from 1954-6 to 2006-10) in the number of patient falls in hospitals and other healthcare facilities. These still occur most frequently near the bedside or in the bathroom, among mentally confused or physically impaired patients, and often involve those with greater comorbidity. Where there might be a break thru is that there is some evidence that patients receiving benzodiazepines are significantly more prone to incur a fall. The reasons that hospitals during the past half century have demonstrated a significant increase in patient falls per discharge or per patient days are numerous, are not completely surprising, and are certainly interrelated: improved accident reporting systems; on the average older, more impaired, more acutely ill, and more heavily sedated patients; and, less time spent by nursing personnel at the bedside. Conversely, patients are better served with greater nurse staffing ratios since they tend to reduce the number of patient accidents. Most safety committees are not as effective as they should be, since they have difficulty in implementing a long-term, aggressive, facility-wide prevention program. Within that context, it may be worthwhile to discuss the advantages of nursing leadership rather than a representative of the facility’s management staff to chair these safety committees.

Key words: Patient falls; hospital safety committees. 3

Over the past six decades, patient falls have been the focus of literally hundreds of published studies, each one of them focusing on acute and other healthcare facilities becoming safer environments. This half-century is generally considered history- ically to be an unusually productive period where western industrialized nations have experienced significant enhancements in the medical sciences; and, as a result of these advances, major modifications were needed and then implemented on how providers are to be reimbursed by third-party payers. Therefore, the question arises: In this “new environment,” why has the vast number of epidemiological studies of patient falls not led the way to significantly fewer discharges without a prior incident? In the mid-1950s, there were just a few studies of patient falls in the literature.(1-3) Since then numerous reports have been published around the world spanning Australia,(4) Canada, (5)Israel,(6) Italy,(7) Spain,(8) Switzerland,(9) Taiwan, (10) and the United Kingdom (U.K.).(11-12) If you review the references of just one American(13) and one U.K.(14) paper, it is easy to conclude that since the mid-1950s, virtually hundreds of such studies have been added to the literature. Certainly this suggests that patient falls is a topic that has generated considerable interest particularly among physicians and nurses, who want to assure the public that their healthcare facilities offer a safe environment where they receive quality patient care. Unfortunately, inpatient falls are relatively common, some of them considered avoidable, and only a few of them resulting in a serious injury and a prolonged hospital stay. It is in this 4 context of assuring patients in various healthcare facilities of improved safety, that the purposes of this paper are to analyze: (a) whether during the last six decades their incidence per discharge or patient days has decreased or not; (b) whether the pattern of patient accidents has significantly changed, and if so how?; and, (c) what still needs to be accomplished to make our healthcare facilities a safer environment? A proposed outcome of all these efforts should obviously be fewer patient falls as the employees of various healthcare facilities became better informed about their causation. Some Findings in the 1950s Compared to Today To undertake an analysis of patient falls in the 1950s compared to more recently, some annual accident rates reported in the literature have been selected for review at the outset for study: According to the incident reports (most often nurses filling out a special form by hand) at Mount Sinai Hospital (New York City) during the years 1954 through 1956, there were 2,036 patient falls. (1) There were 70,048 admissions to the hospital during the three years included in this study, suggesting an accident rate of 28.5 incidents per l,000 patient admissions or 2.5 accidents per 1,000 patient days. These rates compared favorably with Williams’ findings (1947) (2) at the University of Illinois Hospital and are consistent with a survey of a group of British hospitals after World War II. (3) Over the last several decades, there have been a significant number of studies (rarely providing average length of stay) focusing on the incidence of hospital patient falls and offer 5 these findings: a. Reported were 18.4 patient accidents per l,000 admissions during a twenty-two month period (1981-82) in a study based in a U.S. 152-bed acute specialty hospital;(15) b. Reported were the rates of falls per 1,000 admissions in the psychiatric, elder care, and rehabilitation departments in 1998 in a 2,000 bed Israeli teaching hospital and they were significantly higher than in an earlier period (1978-81). (16) Rates of 115, 91, and 85, respectively, per 1,000 admissions were cited in 1998 compared with 34, 9, and 19, respectively, in the 1978-81 period. The percentage of reported falls in the young age group (under 50 years of age) was also significantly higher in the 1998 survey; c. Reported in fiscal year 2000 were 75.0 incidents per 1,000 admissions, after randomly selecting one teaching, one large community, and two small community hospitals in five Canadian provinces; (5) d. Reported were 2.63 falls per 1,000 patient days based on a study from 1997 to 2002 in an U.S. academic acute care hospital; (17) e. Reported were 7.5 falls per 1,000 admissions in a 300- bed urban public hospital in Switzerland from 1999 to 2003.(9) There were huge differences in rates per 1,000 admissions by service: geriatrics 24.8; internal medicine 8.8; and, surgery 1.9; f. Reported were 3.l falls per 1,000 patient days during January 2001 through June 2002 at a large U.S. academic teaching hospital; (18) g. Reported were hospital patient accidents of 4.4 per 6 l,000 patient days in 2002 in Taiwan;(10) h. Reported were findings from a study undertaken in the U.K. from September 2005 through August 2006 of almost 500 institutions (a mix of acute hospitals, community hospitals, and mental health units), the mean standardized rates of falls per 1,000 patient days were 4.8 in acute hospitals, 2.1 in mental health units, and 8.4 in community hospitals; (11) and, finally, i. Reported was a mean fall rate of 3.65 per 1,000 patient days during a 54-month period (July 2006-December 2010) in a longitudinal study with a sample of 1,524 hospitals participating in a National Database for Nursing Quality endeavor. (19) Although there is significant fluctuation among the above findings, one should conclude that over the last half century that hospitals and other healthcare facilities have generally experienced an increase in the number of patient falls per 1,000 admissions or days. If you compare the 1954-56 Mount Sinai Hospital data (1) to a broad-based study a half century later,(19) it is estimated that there has been a 46% increase in patient falls per 1,000 patient days.

The probable reasons are voluminous and are discussed later.

High-Risk Factors Related to Patient Falls There are several repeating themes, whether it was in the 1950s or most often replicated recently, that either delineate key factors or describe specific-types of patients who most frequently experience falls. In fact, there has been minimal changes over the last half century in the profile of the patient who frequently has an incident. It is critical to study these somewhat distinct variables, all of them needing to be considered when developing a sound patient safety program for any healthcare facility: 7

a. A few key variables in studying patient accidents. The Mount Sinai Hospital study (1) using mid-1950 data found that twice as many falls occurred among males as females. But more critical is the incident rate among patients admitted to a ward (a Florence Nightingale-type accommodation of six or more patients in one room) was 34.9 per 1,000 admissions as compared to a rate of 28.6 for semi-private (usually a two-bedded room), 10.4 for private (a single occupant), and 5.7 for obstetrical patients. Noteworthy, the very young and the old had the most accidents even when adjusted for days of patient exposure. Fortunately, 90% or more of hospital falls resulted in “no detectable” or a “slight injury,” and less than 5% resulted in a serious trauma. b. Time of day for most falls. Is nighttime, when less personnel is around, the period of more frequent patient falls? Contrary to general opinion, more accidents occurred at Mount Sinai Hospital during the day shift than at any other time.(1) Most bedside falls, a result of patients getting out of or returning to bed, however, happened at night. This may be explained by the fact that more patients are in bed at night, fewer personnel are on the floors, and darkness may be a psychological cause during these hours. c. Cognitive factors. An Australian study (4) in large Melbourne teaching hospital reported that the Diagnosis Related Group (DRG) with the highest proportion of falls (24%) was “dementia and other disturbances of cerebral function;” and, these patients had a significantly longer average length of stay and a higher cost per discharge. These findings replicate the earlier Mount Sinai Hospital study (1) where patients with neurologic, 8 psychiatric, and orthopedic diagnoses on admission were involved in significantly more incidents than expected. d. Patients who have one fall are prone to experience another soon thereafter. There is reasonably solid evidence(1, 9, 11, 15 ) that if a patient has one fall there is more than a reasonable chance they will soon thereafter have another. During the three-year study at Mount Sinai Hospital, (1) roughly ten percent (9.7%) of the patients having an accident accounted for 23.3% of the all the falls included in the study. Approximately half of the repeated falls occurred within five days of the first incident.

These findings were repeated in a 152-bed acute hospital study during 1981-2 (15), where patients that had fallen once had a subsequent fall rate of 91.7 per 1,000 admissions compared to an overall rate of 18.7 for first falls. Half of all these falls occurred in or in route to a private bathroom that was part of the patient room. The trend toward private rooms with baths and greater emphasis on patient ambulation may have simultaneously increased exposure to accidents to, in, and back from a bathroom. What needs some further study is whether the current trend of patients maintaining function and physical activity is a major factor in these repeated accidents?

e. Location of patient accidents. In the Mount Sinai Hospital study (1), the most falls occurred at the bedside (61.0%); in the bathroom (11.5%); in the hallway (11.1%) and, in the outpatient department (3.1%). It is estimated that 65% of all patient falls occurred in the patients' rooms or in wards within a 10 foot 9 radius of the patient’s bed. These early findings of where falls arise most frequently were replicated in a number of more recent studies. (9, 15, 16) f. Most falls result in minor injury. In a study (9) conducted in a 300-bed urban, public hospital in Switzerland from 1999 to 2003, two-thirds of the patients who fell sustained no injury. In 30.1% and 5.1%, respectively, minor and major injuries were observed. Not surprisingly, there was a twofold increase in the proportion of patients in the geriatric department who experienced major injuries compared to the department of internal medicine. The overall evidence suggests that the patient who has impaired mobility and impaired cognition, including disorientation and confusion, is far more likely to be subject to a serious fall. g. Impact of a safety committee. Enloe et al. (17) provides a particularly interesting study in the sense that it traces the incidence of falls in a 471-bed academic health center over a six- year period (1997-2002), while simultaneously underway was an ongoing internally-organized accident prevention program. The fall rates decreased (3.6%/annum), but the decline was almost solely attributed to one department. Psychiatry had the most significant decline in fall rate over time, likely influenced by new medications with fewer side effects, a change in patient orientation on admission, and continuing safety education for staff. This institution’s long-term results are consistent with Dempsey’s evaluation (20) that a fall prevention program five years after implementation showed that the gains made in decreases in falls in the first year were not sustainable over time. h. Probably the key variable. A study (2002-3) in a 323-bed 10 teaching hospital in Melbourne, Australia confirms earlier findings in that the DRG with the highest proportion (24%) of patient falls was “dementia and other chronic disturbances of cerebral functions.”(21) Particularly noticeable with a high percentage of falls, longer average lengths of stay, and higher patient costs were those with the DRG of “stroke with severe/complicating diagnosis and procedure.” It is obvious that healthcare facility accident prevention programs need to focus on patients with these types of diagnoses. Impact of Drugs on Patient Falls As early as 1936, Haigh and Hayman (22) suggested that sedatives, especially phenobarbital, might be a factor in patient falls. In the Mount Sinai Hospital study, (1) sedatives, narcotics, stimulants, and other drugs were considered factors in only 5% and anaesthetics in 3% of the cases. A detailed review of each patient’s chart involved in a fall, rather than mostly relying on the incident report that most frequently was completed by a nurse who was most interested in describing the accident and condition of the patient, might have resulted in a more accurate analysis. There is growing evidence based on studies published during the last two decades that patients taking one or more benzodiazepines (very often temazepan), most frequently prescribed to enhance sleeping at night times, have increased the risk of falling near the bedside. (22) Another study (14) noted that a significant fall risk factor is a prescription of “culprit drugs” (especially sedatives/hypnotics) in combination with gait instability, agitated confusion, and urinary incontinence/ 11 frequency. Frels et al. in a 2002 U.K. study (23) found that 46% of those who had an incident were taking one or more benzodiazepines compared with 27% of the control patients. Temazepam was the main benzodiazepine used by over 95% of cases and controls. Falls were least likely to occur during visiting hours with a peak incidence during night time. For safety reasons, it was recommended that finding an alternative to benzodiazepines for night sedation for older patients needs to be sought. (24) Financial Impact In a 2004-06 study (25)at a three-hospital mid-western (U.S) health care system, 57 patients experienced a serious fall related injury (fracture, subdural hematoma, any injury resulting in a surgical intervention or death) with a cost ranging from $5,808 to $29,450 and on the average, the patient remaining in the hospital for an additional 6.9 days. For legal reasons, there is a resistance to publish the fiscal impact of patient falls. But it must be significant considering that there were probably 724,000 patient accidents annually and about 2,500 being serious calculated by simply multiply an accident rate of say 20.0 accidents/1,000 admissions (a very low rate)times the 362.2 million inpatient admissions to U.S. hospitals in 2012. Prevention Approaches Almost all hospitals and other healthcare facilities have some form of safety committee often chaired by a member of the institution’s executive staff with representatives from nursing, housekeeping, food service, plant operations, and other 12 departments. Oliver et al. (26) in 2000 analyzed the then published hospital fall prevention programs to determine whether or not they had any favorable impact on preventing falls. They decided that these committees reduced fall rates in the 9% to 12% range. A somewhat later study (27) offered no conclusive evidence that hospital prevention programs reduced the number of falls. The most recent study concluded that these safety committee efforts decreased the number of falls by 14%. (29) Although these safety committees to date have not achieved a compelling long-term reduction in patient accidents, the themes that appear to be pertinent to be successful in reducing falls focuses on: “leadership support, engagement of front-line staff in program design, guidance of the prevention program by a multi- disciplinary committee, pilot-testing interventions, use of information technology systems to provide data about falls, staff education and training, and changes in nihilistic attitudes among fall prevention.”(28) Reasons for More Falls Being Reported There are a significant number of reasons why patient fall rates in hospitals and in other healthcare facilities have increased, even though more data have been collected and analyzed in the past half-century concerning who, why, and where these accidents occurred. In addition, almost every one of these facilities has an active safety committee that attempts to curtail these incidents. Some reasons why they are experiencing and reporting more patient falls, and some approaches that might be used by safety committees to reduce these numbers follow: a. Improved reporting systems and their analysis. Falls and 13 related injuries are the most frequently reported adverse event among adults in hospital settings. As a result, the facility’s nursing administration philosophy toward what constitutes a patient accident is so critical and may be more consequential than the actual process utilized to report such occurrences. The nursing department’s view of when a fall should be reported or not must be widely understood in the organization. Also, the details to be included in the incident reporting process (may be “on line” or a separate form) is important in terms of future study purposes. In the last half century, the reporting approach in healthcare facilities has improved and might ideally include what Donabedian(30) called the structural, process, outcome, and balancing measures to gain an overview as well as a detailed account and impact of the patient fall. It is obvious that such improved data collection should result in higher rates of patient accidents for the facility as well as improving the data collection so developing better accident prevention strategies will be achieved, with the anticipation that these steps should eventually reduce the number and the severity of falls. Patient fall studies, including their rates per admissions/ days, are probably influenced by variables: Are all accidents, incidents, and falls at your healthcare facility reported on the same form? Or, does a patient fall require that a physician or a nurse fill out a form that is used exclusively for a patient fall? Are these incidents reported preferably by asking specific statements rather than raising questions? And, are they processed “on line” (included in an electronic health record) rather than on 14 a special form filled out by hand? Are falls documented only in the patient’s chart or also via an incident report? Suspect no one really knows which of these alternatives work most effectively, but a special fall-accident report submitted “on line” that encourages the responsible person for the input to respond to the specific variables outlined by Donabedian (30) and those contained in this paper would probably be most helpful when studying current and deterring future falls. In fact, a user friendly accident reporting system might tend to increase the number of patient falls reported. Because of all the variables outlined above in each hospital’s reporting system, it is doubtful whether inter- institutional comparisons of patient fall rates are particularly meaningful. This suggests that the discussion early in this paper related to incidence rates might be more meaningful in terms of historical and descriptive for one institution rather than comparative-analytic purposes for a number of similar facilities. b. Age of patients and disability. In the United States, the proportion of the population aged 65 years of age or older is expected to increase from approximately 43.1 million in 2012 to an estimated 71.0 million in 2030; and, the number of persons 80 years or older is projected to increase from 9.3 million in 2000 to 19.5 million in 2030.(31) Meanwhile, hospital inpatient utilization has experienced an epidemiological evolution in the leading causes of death from infectious disease and acute illnesses to chronic disease and degenerative illnesses. This transition, in conjunction with an increasing age distribution, has a significant impact in terms of hospitals and other related 15 facilities experiencing more patient accidents. Hospitalized patients are generally more often disabled today than they were 60 years ago whether it is related to a stroke (32), diabetes (33) or the trend from acute to chronic coronary heart disease (CHD) (34). Overall hospitalization rates for CHD has decreased at a young age, but increased at very old age, another example of why hospitals have more patients today than 60 years ago, who are more prone to have a fall. c. Case mix of inpatients. Based on DRGs, there is some evidence that hospital case mix in U.S. hospitals is becoming more acutely ill, (35) but this may be more related to institutions playing with “DRG creep” when they attempt to gain additional revenues. What is more obvious is that hospitals have shortened their average length of stay (ALOS) from 7.5 days in l980 (after the Mount Sinai Hospital study was undertaken) to an ALOS of 4.5 days in 2012. The nation’s hospital admission rate has declined from 177.4/1,000 persons in 1980 to 113.0/1,000 persons in 2012. The “easier cases” that generated many admissions 60 years ago, are now frequently admitted to an ambulatory surgical center or treated in an outpatient area. The average hospital inpatient today is more critically ill than a half century ago; and, the hospital has the fiscal incentives related to DRGs to discharge them as soon as clinically possible. All of these factors culminate in many more acutely ill patients in-house, who are more prone to have a fall. This may be the major driving force why our patient fall indices are still increasing. Simply, there are a higher percentage of accident prone patients in our hospitals and other healthcare facilities today than there were 60 years ago. 16

d. Less hospital personnel at bedside. Superior nursing personnel with enhanced academic credentials are thought to be critical to reduce drug errors and patient falls. Among all hospital employees, the nursing staff is the group most responsible for direct patient care. Unfortunately, they are being saddled with an increasing number of peripheral responsibilities that take them further away from bedside duties. That nurses might be spending as much as 75% of their shift away from patients is of obvious concern. What seems to be increasingly worrisome is that nurses feel so pressured to secure positive patient satisfaction scores to the point that their interactions with patients too often can seem artificial, may be even scripted. This could be another reason why there has been an increase in patient falls during the last half century in hospitals and other related healthcare facilities. Hitcho et al. (36) reported that patient fall rates were generally higher among those services with higher patient to nurse staffing ratios. This finding is consistent with a few of the early studies focusing on the association between increases in nurse staffing levels and enhanced clinical outcomes including a possible reduction in patient falls. (37-40) Since nursing service is the department in a hospital with the greatest number of employees, adding more highly trained RNs has a potentially significant impact of the institution’s fiscal wellbeing. More recent studies have been focusing, for example, more directly on how the level of staffing effects adverse patient care events, including patient falls. Cox et al. (41) reported that the “implementation of fall prevention strategies and higher RN to 17 unlicensed assistive personnel staffing ratios, decreased the likelihood of a fall during hospitalization.” Using unit-level self-reported data from 215 hospitals. Aydin (42) found that less accidents occurred by optimizing staffing skill mix. A study (43) from The Netherlands confirmed the above suggesting that more advanced levels of nursing education was associated with fewer falls. Many additional studies are still needed to determine whether lower patient to nurse staffing ratios are associated with lower incidence of patient falls, where patient acuity is clearly delineated in the analysis. This proposed undertaking suggests a possible research methodology of when a patient accident occurs, that the nursing staffing pattern in quantitative and qualitative terms, and the mean average DRG on the patient unit would be recorded. Although requiring a sophisticated patient accident reporting system this approach would tie nursing staffing, average seriousness of illness and disability on unit, and the patient fall. Conventional wisdom would say that with more qualified nursing personnel available, there would be lesser patient falls; and, one would hope that further research would confirm this view held by some of the nation’s nursing leadership. (44) Possibly there is another way to reduce patient falls. When nurses change shifts, they usually record their reports at their nursing station. With a “return to care” design, nurses make their change of shift reports at the patient’s bedside with the patient participating in the conversation. With the patient involved, the information passed along should be more to the point and the patient perceives being more involved in the healing 18 process. It would be worthwhile studying whether with a “return to care” approach there are less falls or at least less severe ones, particularly in psychiatric and neuro-skeletal units where patients already tend to have a higher incidence of incidents and have longer average lengths of stay. e. Impact of sedation. Conventional wisdom suggests that drug use, whether alcohol, illicit substance abuse, or prescribed drugs significantly increases the risk of falls. There have been a number of studies (7, 23, 45, 46) that report that medications such as benzodiazepines, diuretics, laxatives, sedatives, and anti-depressants increase the likelihood of a patient falling. This finding seems to be particularly pertinent for patients who are 80 years or older. Tideilsaar (13) reported that “some studies have failed to demonstrate a relationship between falls and drugs.” Although he has admitted that most patients who do fall have either taken within a few hours of a fall large doses of laxatives, tranquilizers and hypnotics, diuretics, psychotropics, or cardiovascular drugs. The overall evidence suggests that patients might be significantly safer in terms of patient falls, if they were less heavily medicated, something not easily implemented among today’s critically ill or severely disoriented patients. f. Physical aspects improved. A major contribution of the Mount Sinai Hospital’s accident study(1) was the discussion at safety committee meetings in the mid-1950s in the use of full bed rails to restrain patient falls versus half rails and to lower the height of the bed to the lowest position after completing treatments or tasks. The decision then was to implement half 19 rails. Tzeng and Yin (47) strongly recommended that “low beds should be used for patients at high risk of falling.” If this would be uniformly implemented, the number of patient falls would be reduced and if there was an accident, a shorter distance would be involved. g. Effectiveness of safety committees. The current agendas of most safety committees include medical errors, patient accidents, and physical plant issues. These three topics might be too broad a scope in a large institution for one committee meeting once a month for 90 minutes. The option might be to form sub- committees for each of the more narrowly defined areas of study, and have the sub-committees summarize their findings and offer their recommendations to the full safety committee. Based on the discipline of the senior authors of the most frequently published articles related to patient falls, nurses rather than physicians or representative of the institution’s executive staff might chair the hospital’s safety committee. More discussion at such meetings thereby would tend to be patient- centered, and what nursing and other departments can do to reduce patient accidents. Although the activities of environmental services, maintenance, dietary, physical and occupational therapy, and other departments can affect patient accidents, the central core of patient accidents is related to nursing service activities. If the hospital is determined to reduce its number of patient accidents, it needs to continually keep “on the heat,” particularly focused on the high-risk clinical areas and those patients that have had one fall. If a patient accident is reported 20 on line, is there an automatic warning posted that the patient is more likely to have another accident within five days? Hospitals frequently report to the public the results of their patient satisfaction surveys. May be what needs to occur is for the hospital to post for its employees (or at least for the nursing department), the number and the incident rates of patient falls by patient unit. The usefulness of this recommendation is that it clearly brings to the attention of those receiving the message the importance of reducing patient incidents. Concluding Comments Almost sixty years ago when sitting in safety committee meetings at New York City’s Mount Sinai Hospital,(48) with the then forthcoming advances in the medical sciences and the changes in hospital reimbursement incentives, one would not have predicted that our health facilities would experience nationally and internationally more patient accidents. With an aging population and more ambulatory versus inpatient services, patient accidents will become an increasing problem for governing boards, medical staffs, nurses and other employees, defense attorneys, and insurance underwriters, who are already concerned about falls because of patient safety issues, the occasional poor publicity in the press, and the number of claims filed against healthcare facilities. If we are going to succeed in reducing falls in healthcare facilities, additional studies will be needed on these and other questions: is there an effective alternative to our current usage of benzodiazepines?; although potentially effecting the fiscal well-being of the facility, how much and what type of professional 21 nurse staffing is required to significantly reduce the number of accidents among patients with greater comorbidity?; what patient fall reporting system will be most effective to focus on avoiding patients having a second (repeat) accident - - recording the staffing pattern and average DRG on nursing unit?; if you focused more on patients optimizing function and activity, would that be of some assistance in decreasing the number of patient falls?; what role does patient safety orientation on admission have on accident prevention?; and, what are the critical factors in making safety committee activities effective in terms of achieving a long-term decrease in falls? In the next several decades, with health facilities experiencing continual cutbacks in revenues and concurrently admitting a higher percentage of more acutely ill, aged patients, it is so likely that the topic of preventing patient falls and related studies will gain increasing public and professional attention. 22

REFERENCES

1. Weil TP, Parrish HM. How did it happen? An analysis of 2,036 patient accidents at New York’s Mount Sinai Hospital. Hospitals JAHA 1958;32:43-8.

2. Williams WR. The patient’s accident pattern. Hospitals JAHA. 1948;22:39-41.

3. Snell WE. Accidents to patients in hospitals. Lancet. 1956;268:1202-04.

4. Hill KD, Vu M, Walsh W. Falls in the acute hospital setting - -impact on resource utilization. Aust. Health Rev. 2007; 31:471-7.

5. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170;1678-1686.

6. Salameh E, Cassuto N, Oliven A. A simplified fall-risk assessment tool for patients hospitalized in medical wards. Isr. Med. Assoc. J. 2008;10:125-9.

7. Passaro A, Volpato S, Romagnoni E, Manzoli N, Zuliani G, Fellin R. Benzodiazepines with different half-life and falling in a hospitalized population: The GIFA study. Gruppo Italiano di Farmacovigilanza nell’Anziano. J. Clin Epidemiol. 2000:53:1222-9. 23

8. Aranda-Gallardo M, Morales-Asencio JM, Canca-Sanchez JC, Toribio-Montero JC. Circumstances and causes of falls by patients at a Spanish acute care hospital. J Eval Clin Prac. 2014;20:631- 7.

9. Schwendimann R, Buhler H, De Geest S, Millsen K. Characteristics of hospital inpatient falls across clinical departments. Gerontology. 2008;54:342-8.

10. Chen YC, Chien SE, Chen LK. Risk factors associated with falls among Chinese hospital inpatients in Taiwan. Arch. Gertol Geriatr. 2009;48;132-6.

11. Healey E, Scobie S, Oliver D, Pryce A, Thomson R, Glampson B. Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports. Qual Saf Health Care. 2008;17:424-30.

12. Booth CM, Moore CE, Eddleston J, Sharman M, Atkinson D, Moore JA. Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice. Postgrad Med J. 2011;87:694-9.

13. Tideiksaar R. Falls in the elderly. Bull N Y Acad Med. 1988;64:145-63.

14. Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk 24 assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004;33:122-30.

15. Morgan VR, Mathison JH, Rice JC, Clemmer DI. Hospital falls: a persistent problem. AJPH. 1985;75:775-7.

16. Kerzman H, Chetrit A, Brin L, Toren O. Characteristics of falls in hospitalized patients. J Adv Nurs. 2004;47:223-9.

17. Enloe M, Wells TJ, Mahoney J, Pak, M., Gangnon RE, et al. J Patient Safety. 2005;4:208-14.

18. Fischer JD, Krauss MJ, Dunagan WC. Birge S, Johnson S, Costantinou E, Fraser VJ. Patterns and predictors of inpatient falls and fall-related injuries in a large academic hospital. Infect Control of Hosp Epidemiol. 2005;26:822-7.

19. Everhart D, Schumacher JR, Duncan RP, Hall AG, Neff DF, Short RI. Determinants of hospital fall rate trajectory groups: a longitudinal assessment of nurse staffing and organizational characteristics. Health Care Manage Rev. 2014;39:352-60.

20. Dempsey J. Falls prevention revisited: a call for a new approach. J Clin Nurs. 2004;4;479-85.

21 Goodwin MB, Westbrook JI. An analysis of patient accidents in hospital. Aust Clin Rev. 1993;13:141-49. 25

22. Haigh E, Hayman JM Jr. When they fall out of bed. Mod. Hosp. 1935;12;45-6.

23. Frels C, Williams P, Narayanan S, Gariballa SE. Latrogenic causes of falls in hospitalized elderly patients; a case-control study. Postgrad Med J. 2002;78:487-9.

24. Merten H, Zegers M, de Bruijne M, Wagner C. Scale, nature, preventability and causes of adverse events in hospitalized older patients. Age and Ageing. 2013;42:87-93.

25. Wong, CA, Reckterwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37:81-7.

26. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Amer Geriatr Soc. 2000;12:1682-9.

27. Coussement J, De Paepe L, Schwendimann R, Denhaerynck K, Dejaeger E, Milsen K. Interventions for preventing falls in acute- and chronic-care hospitals: a systematic review and meta- analysis. J Amer Geriatr Soc. 2008;56:29-36

28. Choi M, Hector M. Effectiveness of intervention programs in preventing falls: a systematic review of recent 10 years and meta- analysis. J Am Med Dir Assoc. 20012;13:188e13-21. 26

29. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:390-6.

30. Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005;83:691-729.

31. CDC. Public health and aging: trends in aging-United States and world wide. Http:www.cdc.gov/mmwr/ preview/ mmwhtml/mm5206a2.htm. Accessed May 3, 2015.

32. Ovbiagele B, Markovic D, Towfighi A. Recent age- and gender- specific trends in mortally during stroke hospitalization in the United States. Inter. J Stroke. 2011;6:379-87.

33. Menke A, Rust KE, Eradkin J, Cheng YJ, Cowie CC. Associations between trends in race/ethnicity, aging, and body mass index with diabetes prevalence in the United States: A series of cross- sectional studies. Ann Intern Med. 2014;161:328-35.

34. Koopman C, Bots ML, van Dis I, Vaartjes I. Shifts in the age distribution and from acute to chronic coronary health disease hospitalizations. Eur. J Prev Cardiol. 2014;July 30 Pii2047487314544975.

35. Steinwald B, Dummit LA. Hospital case-mix change: sicker patients or DRG creep? Health Aff. 1989;8:35-47. 27

36. Hitcho EB, Krauss MJ, Birge S, Dunagan WC, Fisher I. et al. Characteristics and circumstances of falls in a hospital setting. J Gen Intern Med. 2004;19:732-9.

37. Needleman J, Buerhaus P, Matike S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care to hospitals. N Eng J Med. 2002;346;1715-22.

38. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288;1987-93

39. Unrah L. Licensed nurse staffing and adverse events in hospitals. Med. Care. 2003;41:142-52.

40. Blegen MA, Vaughan T. A multisite study of nursing staffing and patient occurrences. Nurs Econ. 1998;16:196-203.

41. Cox, J, Thomas-Hawkins C, Pajarillo E, DeGennaro S, Cadmus E, Martinez M. Appl Nurs Res. 2015;28:72-82.

42. Aydin C, Donaldson N, Aronow HU, Fridman M, Brown DS. Improving hospital patient falls. J Nurs Ad. 2015;45:254-62

43. Stalphers D, Brigitte JM, Kaljouw MJ, Schuurmans M. Association between the characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: A systematic review of literature. Int J Nurs Stud. 28

2015;52:817-35.

44. Quigley P, White S. Hospital-based fall program measurement and improvement in higher relability organizations. OJIN. 2013;18:5.

45. Ray WA, Griffin MR, Downey W. Benzodiazepines of long and short elimination half-life and the risk of hip fracture. JAMA. 1989;262:3303-7.

46. Gales BJ, Menard SM. Relationship between the administration of selected medications and falls in hospitalized elderly patients. Ann Pharmacother. 1995;29:354-8.

47. Tzeng HM, Yin CY. Heights of occupied patient beds; a possible risk factor for inpatient falls. J Clin Nurs. 2008;11:1503-9.

48. Weil TP. An epidemiological study of 614 patient accidents at The Mount Sinai Hospital. An essay presented to the faculty of the Department of Public Health, Yale University in candidacy for the degree of Master of Public Health, 1958, pp 67-72.