High Fall Risk Patient Dies Following Failure to Implement Safety Measures

 This case involves a seventy-one-year-old female who presented to the emergency department with diarrhea, orthostatic hypotension, dehydration, and weakness. She had nausea and vomiting for 23 days straight prior to her admission. The patient noted that prior to presenting at the emergency department she had previously seen her primary care physician for the same symptoms. The decision was made to admit the patient over night to treat her symptoms. The treating physician put her on a regimen of medications which included Ambien, GoLytely, Aspirin, and Heparin. The patient was having recurrent bouts of diarrhea and frequently had to get up to go to the commode. The patient’s age, medications, hypotensive state and frequent commode use put her at substantial risk of a fall. However, no bedside alarms were ordered, nor were any special safety precautions taken despite her elevated risk for falling. Hours after the Ambien was administered to the patient, she stood up to use the bedside commode, lost consciousness, and fell backward, striking her head. It was later found that she had suffered a subdural hematoma as a result of the fall. The patient was transferred to the ICU for treatment, but unfortunately, passed away shortly thereafter due to complications as a result of the subdural hematoma. An expert in risk management was sought to opine on the issue.

Question(s) For Expert Witness

Expert Witness Response E-007516

The hospital that treated this patient should have a protocol to instruct the staff on screening patients for safety issues and identifying the level of risk when admitting the patient to the unit or the emergency department. It is the duty of the person or persons stipulated by the hospital’s policy (the licensed nurses who are in charge of the patient, the admitting nurse or the assigned nurse) to document the findings of any fall risk on the initial assessment of the patient at the time of admission. The hospital protocol should have adequate instructions for the staff to follow for patients who are at risk for falling. There can be different monitoring levels depending on the level of risk. Bed alarms are not ‘ordered’ by physicians but their need is determined on a case-by-case basis by nurses. Typically they are only used for patients who are unable to comprehend the need to call for assistance prior to getting out of bed. It is important to note, however, that bed alarms do not prevent falls. They can only serve as a device to alert staff that patients are either exiting the bed or have already exited the bed.

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