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Patient safety: Falls remain stubborn problem

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ECRI’s 2024 list of threats to patient safety includes a familiar challenge: preventing falls. Marcus Schabacker, ECRI’s CEO, discusses an ongoing concern.

In ECRI’s list of the top 10 threats to patient safety in 2024, preventing falls trailed other challenges, including training new clinicians, using new technology such as AI, and barriers to maternal care.

The ongoing challenge in preventing patients from falling ranked 10th on the list. However, Dr. Marcus Schabacker, president and CEO of ECRI, the nonprofit group focused on patient safety, expresses frustration that it remains a lingering problem.

“It is just so disheartening to see that year after year after year, we lose so many patients to preventable falls, and we have tried so hard to make progress there,” Schabacker told Chief Healthcare Executive®. “And we still have such a big issue. And so that's why we put it on the list.”

“We've talked about it so many times, but it's still happening,” he adds. “Thousands of patients having that catastrophic experience, and it is preventable.”

Patient falls were the most common sentinel event in 2022, according to The Joint Commission. Sentinel events are defined as events leading to death, permanent harm, or severe temporary harm.

In 2022, there were 611 sentinel events classified as patient falls, a 27% increase from the previous year, when there were 483, according to the commission. In 2019, the last year before the COVID-19 pandemic, there were 161 sentinel events, the commission said.

Among those falls in 2022, 70% resulted in severe harm and 5% led to patient deaths, the commission said. The analysis covers events that were self-reported to the commission.

The persistent problem of patient falls underscores a deeper frustration, Schabacker says. Patients suffer far too many medical errors and adverse events, and the healthcare industry - and society in general - should be far more alarmed, he says. More than a quarter of Medicare patients suffered adverse events in hospitals, according to a federal analysis. Schabacker has said the healthcare industry has become too complacent with medical errors and adverse events.

“This is where I just continued to be really frustrated, as a clinician, as the leader of ECRI as a person … is that societal complacency,” Schabacker says. “The fact that we have tens of thousands of people dying unnecessarily when they're in our care. I’ve sworn an oath as a physician to not do harm.”

“That’s why we keep pushing,” Schabacker said. ‘That's why we want to make sure that people are aware of those things. And that's why I get out of bed every morning.”

Hospitals should look at designating a point person to be responsible for fall prevention efforts, which would include ensuring appropriate staffing and utilizing technology to prevent falls, such as alarms or video-based patient monitoring, ECRI says. Health systems should also look for ways to improve communication and teamwork to prevent falls.


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