Analysis of selected cases of falls of hospitalized patients
Iva Brabcová 1, Hana Hajduchová 1, Valérie Tóthová 1, Sylva Bártlová 1,
Jozef Filka 2, Martin Doseděl 3, Josef Malý 3, Jiří Vlček 3
1University of South Bohemia in České Budějovice, Faculty of Health and Social Sciences, Institute of Nursing, Midwifery and Emergency Care, České Budějovice, Czech Republic 2University of South Bohemia in České Budějovice, Faculty of Health and Social Sciences, Institute of Laboratory Diagnostics and Public Health, České Budějovice, Czech Republic 3Charles University, Faculty of Pharmacy in Hradec Králové, Department of Social and Clinical Pharmacy, Hradec Králové, Czech Republic
Korespondenční autor: Iva Brabcová (brabcova@zsf.jcu.cz)
ISSN 1804-7181 (On-line)
Full verze:
Submitted:28. 11. 2018
Accepted: 4. 12. 2018
Published online: 31. 12. 2018
Summary
Contemporary state: The falls of hospitalized patients are the most frequent adverse events in the hospital environment that prolong hospitalization and increase treatment costs. Goal: The goal of this study is to identify the causes and other factors causing falls regarding the selected group and recommend preventative and remedial measures. Materials and methods: It is a qualitative analysis of two casuistries of patients who fell during the hospitalization period. In both cases, we analyzed the root causes of falls (Root Cause Analysis). Results: In the first case, the cause of the fall was a sudden collapse of the patient, which resulted in the loss of balance. The collapse was caused by an infection, dehydration and the subsequent orthostatic hypotension. Other factors were the high-risk time (early morning) and insufficient bathroom lighting. In the second case, the fall was caused by the patient’s loss of balance during their morning hygiene regime. In both cases, the subsidiary factors were high age (80+), polymorbidity and pharmacotherapy. Conclusions: Falls, especially in elderly patients, are multifactorial. Preventative and remedial measures should be complex. In both cases, it is necessary to carry out the nursing plan with regards to the current changes in the health condition of hospitalized patients, and to share information on such changes among medical workers.
Keywords: Falls; Hospital; Patients; Prevention; RCA; Risk factors
Literatura
1. Bennett A, Gnjidic D, Gillett M, Carroll P, Matthews S, Johnell K, et al. (2014). Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs Aging 31(3): 225–232. DOI: 10.1007/ s40266–013–0151–3.
2. de Vries M, Seppala LJ, Daams JG, van de Glind EMM, Masud T, van der Velde N, EUGMS Task and Finish Group on Fall-Risk-Increasing Drugs (2018). Fall-Risk-Increasing Drugs: A systematic review and meta-analysis: I. Cardiovascular drugs. J Am Med Dir Assoc 19(4): 371.e1–371.e9. DOI: 10.1016/j. jamda.2017.12.013.
3. Jarošová D, Majkusová K, Zeleníková R, Kozáková R, Líčeník R, Stolička M (2014). Prevence pádů a zranění způsobených pády u starších dospělých – Klinický doporučený postup adaptovaný [Prevention of falls and fall injuries in elderly adults – clinically recommended adapted method]. (2005), Supplement (2011). RNAO. Ostrava: Ostravská univerzita v Ostravě (Czech).
4. JCR (2007). Prevence pádů ve zdravotnickém zařízení: Cesta k dokonalosti a zvyšování kvality [Prevention of falls in the hospital environment: the way to perfection and better quality]. Praha: Grada (Czech).
5. Lee JY, Holbrook A (2017). The efficacy of fall-risk-increasing drug (FRID) withdrawal for the prevention of falls and fall-related complications: protocol for a systematic review and meta-analysis. Syst Rev 6: 33. DOI: 10.1186/s13643–017–0426–6.
6. Mooris EV, Isaacs B (1980). The prevention of fallls in a geriatric hospital. Age and Ageing 9(3): 181– 185. DOI: 10.1093/ageing/9.3.181.
7. MZ ČR (2011). Rezortní bezpečnostní cíle Ministerstva zdravotnictví ČR v oblasti kvality a bezpečnosti zdravotních služeb na období červen 2011 až duben 2012 [Safety objectives of the ministry of health of the Czech Republic regarding the quality and safety in health services from June 2011 to April 2012]. [online] [cit. 2013–05–27]. Available from: http://www.mzcr.cz/…bezpecnostni- cile-_1837_15.html (Czech).
8. MZ ČR (2012). Metodika sledování nežádoucích událostí ve zdravotnických zařízeních lůžkové péče. In: Věstník Ministerstva zdravotnictví České republiky, částka 8, pp. 20–27 [Methodology of monitoring adverse events in bed care facilities]. [online] [cit. 2013–05–27]. Available from: http:// www.mzcr.cz/…a/dokumenty/ vestnik-c8/2012_6865_2510_11.html (Czech).
9. Oliver DH, Haines F, Terry P (2010). Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med 26(4): 645–692. DOI: 10.1016/j.cger.2010.06.005.
10. Rubenstein LZ, Josephson KR (2006). Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am 90(5): 807–824. DOI: 10.1016/j.mcna.2006.05.013.
11. Seppala LJ, van de Glind EM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, et al. (2018a). Fall-risk-increasing drugs: a systematic review and meta-analysis: III. Others. J Am Med Dir Assoc 19(4): 372.e1–372.e8. DOI: 10.1016/j.jamda.2017.12.099.
12. Seppala LJ, Wermelink AMAT, de Vries M, Ploegmakers KJ, van de Glind EMM, Daams JG, et al. (2018b). Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics. J Am Med Dir Assoc 19(4): 371.e11–371.e17. DOI: 10.1016/j.jamda.2017.12.098.
13. Slouka D, Frei J (2016). Akutní stavy v otorinolaryngologii [Acute conditions in otorhinolaryngology]. In: Frei J, et al. (Eds). Akutní stavy pro nelékaře [Acute conditions for non-medical workers]. Plzeň: Západočeská univerzita, pp. 147–153 (Czech).
14. Slouka D, et al. (2018). Otorinolaryngologie [Otorhinolaryngology]. Praha: Galén (Czech).
15. ÚZIS (2017). Systém hlášení nežádoucích událostí. Nežádoucí události za 1. pololetí roku 2017. Pády [System of reporting adverse events. adverse events in the first half of 2017]. [online] [cit. 2018–12–03]. Available from: http://shnu.uzis.cz/…017-1_NU_PAD(1).pdf (Czech).
16. Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA (2009). Meta-analysis of the Impact of 9 medication classes on falls in elderly persons. Arch Intern Med 169(21): 1952–1960. DOI: 10.1001/archinternmed.2009.357.
17. Zákon č. 101/2000 Sb., o ochraně osobních údajů. In: Sbírka zákonů České republiky, částka 32/2000 [Act No. 101/2000 Coll. on GDPR. In: The collection of laws of the Czech Republic, part 32/2000] (Czech).
