Presentation
Using Human Factors and Ergonomics Principles to Prevent Inpatient Falls in a Rehabilitation Department: An Interventional Study
DescriptionBackground and Objectives: Inpatient falls are frequently reported incidents in hospitals around the world and significantly challenge healthcare systems. Studies conducted in the last decade emphasize the importance of addressing this problem and estimate that in the United States alone, between 700,000 and one million patients fall in hospitals each year, with approximately 250,000 patients injured and about 11,000 dying as a result of the fall. Most falls are predictable, and simple risk assessment tools for patients can predict more than 70% of them. Falls cause a significant economic and physical burden to patients, families, and hospitals, leading to increased mortality rates and decreased quality of life, extended hospitalization, high treatment costs, and legal expenses. Patients and relatives may also lodge complaints, bringing up litigation issues about hospital services and staff competence and, as a result, affecting the reputation of the hospital and their trust in staff.
Hospitals implement various guidelines to prevent falls, including identifying high-risk patients. However, there is considerable variation among the guidelines, which adds to the confusion about the correct approach to prevention. Despite the growing knowledge regarding hospital patient falls, the information does not include analysis and treatment strategies tailored to unique inpatient departments such as rehabilitation.
Our research objectives included introducing the human factors (HF) principles to reduce inpatient falls from a systems engineering perspective. We studied the factors contributing to patient falls in the rehabilitation department and developed a fall prevention strategy in collaboration with the care team, the patient, and their family members based on robust Human Factors Engineering approaches.
Methods: We conducted a mixed-methods interventional study involving a multidisciplinary team in the rehabilitation inpatient department at Barzilai Medical Center, an acute public hospital with around 35 inpatient beds in Israel.
The research stages included:
1. We collected and analyzed data from 206 inpatients with fall incidents in the Rehabilitation department between 2019 and 2023.
2. We conducted 25 in-depth interviews with the rehabilitation inpatient department staff members, patients, and their family members.
3. We conducted ethnographic observations in the department to analyze the staff work processes and identify key pain points.
4. A hospital falls review team was formed in August 2023 to plan and implement the program, and the team included the care team and patients in the rehabilitation department.
The implementation of the intervention began in October 2023. With the outbreak of the Oct 7th war in Israel, the rehabilitation department had to evacuate all patients to a protected building. The department staff implemented adjustments to the intervention program to prevent patient falls even during emergencies. The number of inpatients was reduced to about 40% of full capacity (15 beds), all patients were situated in one large hall, the nursing staff was near the patients at all hours, and a treatment hall was set up next to the inpatient hall.
In May 2024, the department returned to routine operation, including full implementation of the fall prevention intervention program.
Findings: The analysis of fall data in the department pre-intervention revealed an average of 4.5 falls per 1000 occupied bed days. 40% occurred during the morning shift, 76% occurred in the patient room, and 51% involved falling from a chair to the floor. In most patient falls, no staff member witnessed the fall in the room, and the patient or family member made no call to a staff member. The in-depth interviews and observations revealed several problems, including a lack of patient awareness of fall risks, insufficient fall prevention information, and inadequate guidance/involvement of family members in fall prevention. Problems in patient-auxiliary staff communication regarding fall issues were also identified. Following the findings, an intervention program was developed that included changes in three areas: 1. Engineering/environmental, 2. Procedural/organizational, 3. Educational. The average fall rates over six months in the department post-intervention revealed a reduction of 25% in the fall rate.
Conclusions: Developing and implementing a tailored and patient-focused intervention program for care management may help reduce patient fall risks. Despite the emergency situation, the department staff successfully implemented a series of fall prevention strategies while adapting to the nature of activities during wartime. The possibility of expanding the implementation and evaluation of the intervention in additional inpatient departments in the hospital should be examined. This research underscores the critical role of customized, multidisciplinary interventions with the participation of staff trained in HF in the quality improvement team in improving patient outcomes, providing a pathway for reducing falls, and enhancing care quality in challenging healthcare environments.
Main recommendations:
• Tailored Interventions Matter: Strategies that address specific service needs of departments like rehabilitation can better address the unique challenges of fall prevention.
• Collaboration is Key: Involving patients, families, human factors experts, and the care team enhances awareness and adherence to fall prevention strategies.
• Adaptability is Crucial: Effective care management can be maintained even during crises, showcasing the importance of flexible approaches in patient safety programs.
• Fostering a patient safety culture is another important HF principle to practice, enabling staff to speak up and be truthful about patient falls with supportive and non-punitive hospital management.
• Broader Application Potential: With positive results in the rehabilitation department, this model could be a blueprint for improving safety across diverse hospital settings.
Hospitals implement various guidelines to prevent falls, including identifying high-risk patients. However, there is considerable variation among the guidelines, which adds to the confusion about the correct approach to prevention. Despite the growing knowledge regarding hospital patient falls, the information does not include analysis and treatment strategies tailored to unique inpatient departments such as rehabilitation.
Our research objectives included introducing the human factors (HF) principles to reduce inpatient falls from a systems engineering perspective. We studied the factors contributing to patient falls in the rehabilitation department and developed a fall prevention strategy in collaboration with the care team, the patient, and their family members based on robust Human Factors Engineering approaches.
Methods: We conducted a mixed-methods interventional study involving a multidisciplinary team in the rehabilitation inpatient department at Barzilai Medical Center, an acute public hospital with around 35 inpatient beds in Israel.
The research stages included:
1. We collected and analyzed data from 206 inpatients with fall incidents in the Rehabilitation department between 2019 and 2023.
2. We conducted 25 in-depth interviews with the rehabilitation inpatient department staff members, patients, and their family members.
3. We conducted ethnographic observations in the department to analyze the staff work processes and identify key pain points.
4. A hospital falls review team was formed in August 2023 to plan and implement the program, and the team included the care team and patients in the rehabilitation department.
The implementation of the intervention began in October 2023. With the outbreak of the Oct 7th war in Israel, the rehabilitation department had to evacuate all patients to a protected building. The department staff implemented adjustments to the intervention program to prevent patient falls even during emergencies. The number of inpatients was reduced to about 40% of full capacity (15 beds), all patients were situated in one large hall, the nursing staff was near the patients at all hours, and a treatment hall was set up next to the inpatient hall.
In May 2024, the department returned to routine operation, including full implementation of the fall prevention intervention program.
Findings: The analysis of fall data in the department pre-intervention revealed an average of 4.5 falls per 1000 occupied bed days. 40% occurred during the morning shift, 76% occurred in the patient room, and 51% involved falling from a chair to the floor. In most patient falls, no staff member witnessed the fall in the room, and the patient or family member made no call to a staff member. The in-depth interviews and observations revealed several problems, including a lack of patient awareness of fall risks, insufficient fall prevention information, and inadequate guidance/involvement of family members in fall prevention. Problems in patient-auxiliary staff communication regarding fall issues were also identified. Following the findings, an intervention program was developed that included changes in three areas: 1. Engineering/environmental, 2. Procedural/organizational, 3. Educational. The average fall rates over six months in the department post-intervention revealed a reduction of 25% in the fall rate.
Conclusions: Developing and implementing a tailored and patient-focused intervention program for care management may help reduce patient fall risks. Despite the emergency situation, the department staff successfully implemented a series of fall prevention strategies while adapting to the nature of activities during wartime. The possibility of expanding the implementation and evaluation of the intervention in additional inpatient departments in the hospital should be examined. This research underscores the critical role of customized, multidisciplinary interventions with the participation of staff trained in HF in the quality improvement team in improving patient outcomes, providing a pathway for reducing falls, and enhancing care quality in challenging healthcare environments.
Main recommendations:
• Tailored Interventions Matter: Strategies that address specific service needs of departments like rehabilitation can better address the unique challenges of fall prevention.
• Collaboration is Key: Involving patients, families, human factors experts, and the care team enhances awareness and adherence to fall prevention strategies.
• Adaptability is Crucial: Effective care management can be maintained even during crises, showcasing the importance of flexible approaches in patient safety programs.
• Fostering a patient safety culture is another important HF principle to practice, enabling staff to speak up and be truthful about patient falls with supportive and non-punitive hospital management.
• Broader Application Potential: With positive results in the rehabilitation department, this model could be a blueprint for improving safety across diverse hospital settings.
Event Type
Oral Presentations
TimeTuesday, April 18:30am - 8:52am EDT
LocationQueens Quay
Patient Safety and Research Initiatives (PS)