Quality Improvement in Health Care (한국의료질향상학회지)

Korean Society for Quality in Health Care (한국의료질향상학회)
권호 표지
DOI QR코드

DOI QR Code

Analysis of Data on Accidental Falls from the Hospital Incident Reporting in a General Hospital

일 종합병원 사고보고시스템 자료를 이용한 낙상 보고 분석

  • Yu-ri Jang (Department of Quality & Patient Safety Team, Veterans Health Service Medical Center) ;
  • Jeong Yun Park (Department of Clinical nursing, University of Ulsan)
  • 장유리 (한국보훈복지의료공단 중앙보훈병원 적정진료실) ;
  • 박정윤 (울산대학교 산업대학원 임상전문간호학)
  • Received : 2022.09.30
  • Accepted : 2023.01.06
  • Published : 2023.06.30
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: The purpose of this study was to analyze data on fall incidents based on a general hospital's incident reporting system. Methods: This study conducted secondary data analysis to gather statistics on fall reports, general characteristics of patients, results of falls, and improvement strategies for fall prevention using the 2017-2019 fall incidents from the incident report system. Results: There were 693 cases reported over three years. Among the fall incidents, three hundred twenty (46.2%) were adverse events, three hundred seventy-three (53.8%) were near misses, and none were related to sentinel events. Five hundred ninety-five (85.9%) were male, with an average age of 74.08±8.99. The falling incidents happened mostly in patients' rooms (410, 59.1%). At the time of the fall, the patients were conscious and alert (607, 87.6%). As a result of the fall, three hundred sixty (51.9%) caused no harm, permanent damage, side effects, or death. Conclusion: The study findings suggest that the fall characteristics of older patients should be considered to establish a fall-prevention strategy tailored to the institution.

Keywords

References

  1. Morris R, O'Riordan S. Prevention of falls in hospital. Clinical Medicine. 2017;17(4):360. 
  2. World Health Organization. Falls [Internet]. Geneva, Switzerland: World Health Organization; 2021 [cited 2021 Sep 29]. Available from: http://www.who.int/news-room/fact-sheets//detail/falls/. 
  3. Korea patient safety reporting & learning system. Patient safety statistical yearbook [Internet]. Seoul, Korea: Korea patient safety reporting & learning system; 2020 [cited 2021 Sep 29]. Available from: https://www.kops.or.kr/portal/board/statAnlrpt/boardDetail.do. 
  4. Sato N, Hase N, Osaka A, Sairyo K, Katoh S. Falls among hospitalized patients in an acute care hospital: Analyses of incident reports. The Journal of Medical Investigation. 2018;65(1.2):81-4.  https://doi.org/10.2152/jmi.65.81
  5. Kang H, Zhou S, Yao B, Gong Y. A prototype of knowledge-based patient safety event reporting and learning system. BMC Medical Informatics and Decision Making. 2018;18(5):110. 
  6. Yoon SJ, Lee CK, Jin IS, Kang JG. Incidence of falls and risk factors of falls in inpatients. Quality Improvement in Health Care. 2018;24(2):2-14.  https://doi.org/10.14371/QIH.2018.24.2.2
  7. Jin M, Ha Y. Influencing factors on hospital fall prevention activities of tertiary hospital nurses and general hospital nurses. Journal of Health Informatics and Statistics. 2017;42(4):361-70.  https://doi.org/10.21032/jhis.2017.42.4.361
  8. Korea veterans health service. Hospital yearbook [Internet]. Wonju, Korea: Korea veterans health service; 2020 [cited 2021 Sep 29]. Available from: https://www.bohun.or.kr/030manage/manage0206_04.php?left=1. 
  9. Cho MS, Lee HY. Factors associated with injuries after inpatient falls in a tertiary hospital. Journal of Korean Clinical Nursing Research. 2017;23(2):202-10.  https://doi.org/10.22650/JKCNR.2017.23.2.202
  10. Kang YO, Song RY. Identifying characteristics of fall episodes and fall-related risks of hospitalized patients. Journal of Muscle and Joint Health. 2015;22(3):149-59.  https://doi.org/10.5953/JMJH.2015.22.3.149
  11. Ministry of Patriots and Veterans Affairs. Status of national merit [Internet]. Sejong, Korea: Ministry of Patriots and Veterans Affairs; 2021 [cited 2021 Sep 29]. Available from: https://www.mpva.go.kr/mpva/selectBbsNttView.do?key=181&bbsNo=54&nttNo=219873&-searchCtgry=&searchCnd=all&searchKrwd=&integrDeptCode=&pageIndex=2. 
  12. Choi EJ, Lee YS, Yang EJ, Kim JH, Kim YH, Park H. Characteristics and risk factors for falls in tertiary hospital inpatients. Journal of Korean Academy of Nursing. 2017;47(3):420-30.  https://doi.org/10.4040/jkan.2017.47.3.420
  13. Korea patient safety reporting & learning system. Patient safety theme reports [Internet]. Seoul, Korea: Korea patient safety reporting & learning system; 2018 [cited 2021 Sep 29]. Available from: https://www.kops.or.kr/portal/board/statAnlrpt/boardDetail.do. 
  14. Chan DK, Sherrington C, Naganathan V, Xu YH, Chen J, Ko A, et al. Key issues to consider and innovative ideas on fall prevention in the geriatric department of a teaching hospital. Australasian Journal on Ageing. 2018;37(2):140-3.  https://doi.org/10.1111/ajag.12528
  15. Lee SY, Lee KS. Nocturia. Journal of the Korean Medical Association. 2015;58(10):892-6.  https://doi.org/10.5124/jkma.2015.58.10.892
  16. Hwang SY, Shin SJ. Predictors of fall prevention behaviors in elderly inpatients. Korean Journal of Health Promotion. 2013;13(2):76-85. 
  17. Lee JY, Lee JH, Jang YS, Kim EC, Ji YG, Park TZ, et al. Status quo and innovative directions for inpatient fall interventions. Journal of Korean Academy of Fundamentals of Nursing. 2020;27(4):356-65.  https://doi.org/10.7739/jkafn.2020.27.4.356
  18. Kim YS, Kim MS, Hwang JI, Kim HR, Kim HA, Kim HS, et al. Experiences in patient safety education of patient safety officer using focus group interview. Quality Improvement in Health Care. 2019;25(2):2-15.  https://doi.org/10.14371/QIH.2019.25.2.2
  19. Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show?. Medical Clinics. 2006;90(5):807-24.  https://doi.org/10.1016/j.mcna.2006.05.013
  20. Hur JY, Kim HJ. Relationship of risk factors, knowledge and attitude to falls in elderly inpatients. Journal of Korean Gerontological Nursing. 2009;11(1):38-50. 
  21. Kim SN. Effects of a multifactorial fall prevention program on physical.psychological function and home environmental hazards in community dwelling low-income elderly. Journal of the Korean Gerontological Society. 2012;32(2):377-95. 
  22. Kim YJ. Nurses' experience of inpatients' falls. Journal of Korean Academy of Fundamentals of Nursing. 2017;24(2):106-17.  https://doi.org/10.7739/jkafn.2017.24.2.106
  23. Bender M, Williams M, Cruz MF, Rubinson C. A study protocol to evaluate the implementation and effectiveness of the clinical nurse leader care model in improving quality and safety outcomes. Nursing Open. 2021;8(6):3688-96.  https://doi.org/10.1002/nop2.910
  24. Korea Institute for Healthcare Accreditation. Hospital accreditation standards(ver3.0) [Internet]. Seoul, Korea: Korea Institute for Healthcare Accreditation; 2018 [cited 2021 Sep 29]. Available from: https://www.koiha.or.kr/web/kr/library/establish_board.do. 
  25. Kobayashi K, Ando K, Suzuki Y, Inagaki Y, Nagao Y, Ishiguro N, et al. Characteristics of outpatient falls that occurred in hospital. Nagoya Journal of Medical Science. 2018;80(3):417. 
  26. Yoon SH, Kim KJ. Nurses' learning experiences from falling accidents on patient safety. Korea Journal of Hospital Management. 2015;20(2):1-14.