Patient Dies After Fall During Transfer

By ThinkReliability Staff

A medical center in California received a fine for an adverse event in which a patient’s fall at the facility resulted in his death.  As a part of the investigation into these types of events, a plan of action to mitigate the risk of similar events occurring in the future.  In order to best determine which events will be helpful in decreasing future risk, a full accounting of the cause-and-effect relationships that led to the incident being investigated can be helpful.  We can develop a visual map of the causes that resulted in this incident in a Cause Map, a visual form of root cause analysis which determines all relevant causes in order to offer the most possible solutions.

We begin our analysis with a summary of the “what, when and where” of the event, as well as determining which of the organization’s goals were impacted.  In this case, the patient safety goal was impacted due to the patient death.  The compliance goal is impacted because the facility was found to be noncompliant with requirements for licensure as a result of this event.  The fine from the state health department can be considered an impact to the organizational goal.  The patient services goal was impacted due to the improper transport of a patient.  Lastly, it was found that equipment was missing necessary safety features.  This can be considered an impact to the property/ equipment goal.

Once we have determined the impacts to the goals, we can begin with one impacted goal and ask “Why” questions to  determine the cause-and-effect relationship that led to the impacted goals.  In this case, we begin with the patient safety goal.  Why was the patient safety goal impacted? Because of a patient’s death.  Why did the patient die? His death was due to rib fractures and internal bleeding.  Why? Because of blunt force trauma.  Why? Because the patient fell out of a geri/bed chair (a device that can be used as a stretcher semi recliner or chair).

To ensure that the causes we include in our analysis are accurate, we include evidence wherever possible.  Evidence allows validation of the inclusion of causes on the Cause Map.  In this case, the evidence for the cause of death is provided by the autopsy report.

In addition to continuing to ask “Why” questions to add more detail to the Cause Map, we can also add additional impacted goals to the Cause Map.  For example, the patient fall out of the geri/bed chair was what caused the noncompliance with licensure that is an impact to the compliance goal.  This noncompliance caused the fine to the facility.   The patient fell out of the geri/bed chair due to inadequate transport, which impacted the patient services goal.

In some cases, more than one cause is necessary to result in the effect.  The inadequate transport was caused by the patient – who had been assessed as a high fall risk – being both left unattended and not secured in the geri/bed chair.  The patient was not secured on the geri/bed chair because it did not have straps.  It’s also possible he was not secured, and was left unattended, because the transport team, who took him to the radiology department to get an X-ray, was not aware of his high fall risk.  Although a transfer form is used to turn the care of a patient over to another team in cases such as this, there was no record on the transfer form that indicated a report being made to the transfer team that would have included information about the patient, including his fall risk.

As part of the investigation, corrective actions are required.  As is typical in these cases, many of the solutions included additional training and education to staff to reduce the risk of these events happening again.  Although usually included as part of the corrective actions for adverse events, training (or re-training) and continued education are some of the least effective solutions in terms of error recurrence.  (After all, presumably the staff had already been trained on the policies and requirements that were already in place at the time of the accident.)  More effective solutions include changes in policy that result in increased patient safety.  For example, in this case the transport policy has been updated to ensure that patients are left in locations where they can easily be monitored.  This of course will not prevent all falls, but may prevent some, and will certainly lead to staff noticing falls quickly.  Even more effective are changes in equipment to make following policies easier.  In this case, the geri/bed chair that was used for patient transport did not have a strap, even though its use was required.  It is unreasonable to expect busy staff to spend their time searching for equipment that has the proper safety equipment.  Rather, ensure that all geri/bed chairs or other transport devices have the required safety devices.  I’m sure you can imagine that it is much more likely for staff to comply with a policy requiring use of safety devices when the devices are available and by doing so, will reduce the risk of patient falls, and patient deaths.

To view the Outline, Cause Map, and recommended solutions please click “Download PDF” above.  Or click here to read the state department of health report.