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Patient Safety
We use this forum to regularly report on findings from patient safety organizations , expert review committees of the Office of the Chief Coroner , and inquests .
Assess risk factors for further falls among seniors
photo : istockphoto . com
Falls remain the leading cause of injury-related hospitalizations among Canadian seniors . And research suggests that falls are the direct cause of 95 % of all hip fractures , leading to death in 20 % of cases . Reviews into several deaths conducted by the Geriatric Long-Term Care Review Committee ( GLTCRC ) urge physicians to recognize their important role in trying to prevent falls among the elderly . “ When an older adult falls , physicians should perform a comprehensive assessment of risk factors for further falls , address those risk factors that are modifiable ( particularly medications ), and document the assessment and plan ,” writes the GLTCRC , a committee of the Chief Coroner ’ s Office .
Recently , the GLTCRC published a report after reviewing the circumstances of the death of a 76-yearold woman who died from complications of a fall at the retirement home where she lived . The woman had a 13-month history of falls , including one that resulted in an intracranial bleed . One of the primary concerns identified in the review was the issue of falls management and safety in the retirement home where the patient lived .
The GLTCRC noted that although the patient was falling frequently , there did not seem to be any documentation of efforts by the attending physician or retirement home staff to assess the ongoing risk of further falls and reduce those risks where possible . “ There was no physician documentation of a falls risk assessment or attempts to reduce risk of falls in the records from the retirement home ,” states the report . “ There was no documented discussion with the decedent ’ s family regarding the approach to safe ambulation and there was no documented Plan of Care to address the decedent ’ s recurrent falls .” While some of the patient ’ s risk factors for falls were not ones that could be changed ( e . g ., history of previous falls , dementia ), there were potentially modifiable risk factors that deserved an assessment , if not change in plan of care that may have prevented her death from a fall , stated the Committee . For example , there was no documentation that would suggest the attending physician and retirement home considered the following :
• Anti-Hypertensive Therapy : Blood pressure treatment targets in the frail elderly need to be modified upwards to avoid the risks of orthostatic hypotension , dizziness and falls . For this frail 76-year-old woman ,
Issue 1 , 2017 Dialogue 39