South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

Updated sentinel event statistics

The Joint Commission’s sentinel event statistics have been updated on The Joint Commission website. Since the sentinel event database was implemented in January 1995 through June 30, 2008, The Joint Commission has received 5,208 reports of sentinel events. A total of 5,336 patients were affected by these events, with 3,713, or 70 percent, resulting in patient death. The 10 most frequently reported sentinel events are:

Wrong-site surgery                                    691
Suicide                                                         641
Operative/post-operative complication  598
Medication error                                          470
Delay in treatment                                       390
Patient fall                                                     307
Assault, rape or homicide                         198
Patient death or injury in restraints         183
Unintended retention of foreign body*    175
Perinatal death or loss of function           159


* Added to reviewable events in June 2005; data represents events reviewed since that time.

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The Washington Post had a recent article about how falls in the elderly lead to death caused by brain injuries.  This is why it is so critical for nursing homes to have sufficient staff to supervise resdients, prevent falls, and have a fall prevention program.  Below are excerpts of the article.

The elderly fear breaking a hip when they fall, but a government study indicates that hitting their head can also have deadly consequences: Brain injuries account for half of all deaths from falls.

The study by the Centers for Disease Control and Prevention is the first comprehensive national look at the role brain injuries play in fatal elderly falls. It examined 16,000 deaths in 2005 that listed unintentional falls as an underlying cause of death.  CDC researchers found that slightly more than half of the deaths were attributed to brain injuries. The other deaths were due to a variety of causes including heart failure, strokes, infections and existing chronic conditions worsened by a broken hip or other injuries sustained in a fall.

"A lot of people don't think a fall is serious unless they broke a bone, they don't think it's serious unless they break a hip. They don't worry about their head," said Pat Flemming, a senior physical therapist and researcher at Vanderbilt University

Each year, one in three Americans age 65 and older fall. About 30 percent of such falls require medical treatment.   Previous CDC research showed that the U.S. death rate from falling has risen dramatically _ about 55 percent _ for the elderly since the 1990s.

As people age, veins and arteries can be more easily torn during a sudden blow or jolt to the head, said Marlena Wald, a CDC epidemiologist who co-authored the study.   That can cause a fatal brain bleed. Other factors can contribute, such as the use of blood-thinners, said Judy Stevens, another CDC researcher and co-author.

The severity of brain injuries isn't always immediately apparent, and some people may not lose consciousness. Wald noted a scenario seen in hospitals in which an elderly fall victim comes in alert and talking, but dies an hour or two later.

The study also found that deaths and hospitalization rates for fall-related brain injuries increased with age. Brain injuries accounted for about 8 percent of hospital stays for non-fatal falls.

There are several steps older Americans can take to try to prevent falls. Exercise can increase leg strength and balance. Glasses or other vision correction measures can help people avoid obstacles. And being careful with the use of drugs that can affect thinking and coordination _ such as tranquilizers and sleeping pills _ can also make a difference.

"Falls are not an inevitable consequence of aging. These head injuries are not inevitable, either," Wald said.

The research is being published in the June issue of a scientific publication, the Journal of Safety Research.

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Journal of Clinical Nursing has an article about a recent study linking the use of sleeping pills containing benzodiazepines to increase falls in nursing homes.
Older patients taking benzodiazepines were 2.9 times more likely to fall   Obviously, patients who fall suffer severe injuries.   Some older patients have impaired cognitive function or limited functional ability and physical strength stemming from chronic physical ailments, increasing their risk of a fall, often when walking or being moved.

In addition, older patients are take multiple medications, whose side effects increase the patients' chances of a fall.  Physical restraints may be used to decrease the possibility of falling and being injured.

"Even if no physical injury occurs, fall victims may develop a fear of falling again and thus reduce their activities as a result," the authors wrote. "This can lead to unnecessary dependency, loss of function, decreased socialization, and a poor quality of life."

The researchers found that use of sleeping pills containing benzodiazepines was significantly associated with fractures supporting the findings of most previous studies.

Patients using wheelchairs and bed rails were less likely to fall, but neither of the associations reached statistical significance. Nevertheless, "the use of these might be regarded as protective or preventative strategies," the researchers said.

Bed rails can cause injuries if patients climb over them, and physically restraining an already agitated individual can increase fear and worsen behavior, they said.   "In addition, restraints can lead to serious complications, including circulatory obstruction, skin tears, incontinence, fractures, and dislocations," they wrote. "These restraints should be used with care and consideration." 

The Study recognized that restraints cannot completely eliminate falls in nursing homes and that they may not be appropriate in every situation, but concluded that "our results support the hypothesis that they might be protective when used selectively together with fewer sedatives, especially benzodiazepines."

Primary source: Journal of Clinical Nursing
Source reference:
Fonad E, et al "Falls and fall risk among nursing home residents"J Clin Nurs 2008; 17: 126-134.

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