One day last October, an 86-year-old woman underwent surgical repair of a fractured hip at a Boston hospital. After the surgery, staff removed the patients' feet from the boots, bandaged her wound and changed her gown. A nurse then released the safety strap around the patient's torso to move the patient for transfer out of the OR. The nurse walked toward the patient's left side so a bed could be placed on the right side for transfer. The patient, still under anesthesia and attached to the breathing tube, fell buttocks first through a gap in the orthopedic table. She struck her head on the floor and fractured her skull.

The patient required a second surgery to relieve internal bleeding. She died a week later from severe head trauma. The anesthesiology resident, the orthopedic resident and two nurses involved in the case were named in a wrongful death suit. The hospital has since adopted a protocol requiring all nurses and doctors to put their hands on the patient before removing the safety belt and making sure that there are people on both sides of the table.

Let's look at your fall prevention plan

As we can see in this case and others, lack of communication is one of the key causes of errors that result in harm to a patient. Your facility's fall prevention plan should be aimed at reducing liability and ultimately decreasing risk to patients. Assess any falls or near-falls by reviewing incident reports and surveying staff to determine the cause. The causes of falls may be:

• Patient-related. This refers to falls or nearfalls as a result of a medical condition such as hypotension or causes related to medications, anesthesia or anxiety. Was the patient alert and aware of time, persons and place before he ambulated? Was this assessment completed at pre-set intervals before ambulating or discharging a patient?
• Healthcare worker- and patient-related. Did nurses support the patient while moving her from chairs to the OR and then on to the surgical table? When staff removed the patient from the surgical table, did a nurse have a hand on the patient to ensure that she was safely placed in a recovery chair? When getting dressed for discharge, was the patient stable? Did someone help the patient dress?

After discharge, did the patient have a hard time getting into a vehicle to go home? (Many patients have difficulty lifting themselves into SUVs.) Did the discharge nurse have her hands on the patient until he was securely in the vehicle? If the patient was large, was there more than one nurse to assist in getting the patient into the vehicle?

• Facility-related. These causes include safety policies or equipment that don't follow standards, such as unlocked brakes, a lack of assessment for fall risk upon the patient's admission and wet floors.
• Information-related. Were discharge-planning documents clearly written? Did the patient read them? Did the patient know how long someone would be needed at home to help them after discharge? What type of assistance did the patient require with ambulation? Was the caregiver instructed in assistance with ambulation?

Communication is key
A patient admitted to our care is vulnerable and dependent on the competent care of doctors and nurses, especially when the patient is under anesthesia in the surgical suite. When human error occurs and a patient is harmed, we have violated the trust of our patients and are deemed negligent by law. Everyone loses. The costs to healthcare organizations, physicians, nurses and patients are personally, professionally and financially profound.

This year, the Joint Commission published 16 National Patient Safety Goals aimed at protecting patients and keeping facilities free of injury. Goals 9 and 9B are aimed at reducing patients falls. A 2007 Joint Commission report found that there was a 6.2 percent non-compliance rate for this standard. The reasonable and prudent physician or nurse wouldn't tolerate non-compliance and place the facility in the position to defend itself in a wrongful death or injury case. You must determine top-down that there will be a no-tolerance policy for non-compliance of patient safety standards.