Hospitals wage war against patient falls

The effort is laudable, as increasing public awareness of these events - and denying payment of related care in some cases - will help reduce them. But the effort suffers from one flaw. It casts too wide a net over the events it chooses to focus on. In so doing, it may create more confusion than clarity.

The report lists 338 serious reportable events in Massachusetts hospitals last year. These are broken into 28 categories, as required by the Department of Public Health. These 28 include things that unquestionably should not happen in a hospital: wrong patient surgery, wrong body-part surgery, discharging an infant to the wrong person, a patient death because of a medication error. But these egregious situations represent only a tiny fraction of the total. Almost 70 percent of the 338 events last year were from one category - falls resulting in death or serious injury.

Recently I had the privilege of shadowing or “walking in the shoes’’ of a number of caregivers in my hospital system. I walked with nurses and physicians, patient care assistants and patient transporters. I learned much from this experience, including new insight into the nature of falls.

I saw signs in patient rooms that said “Call Before You Fall.’’ I saw patients wearing special socks with rubber treads. I saw bright colored signs and wristbands identifying patients as being at high risk for a fall. And I saw alarms alerting the nurse if a patient attempted to get out of bed - some even recorded the voice of the patient’s spouse warning them to get back into bed. In short, I saw extraordinary efforts to try to prevent falls. And yet, patients keep falling. Why?

I found the answer in other things I experienced. I saw a patient suffering from dementia who, despite repeated warnings, kept getting out of bed believing she was returning home that day. I heard stories of frail elderly women who got up on their own because they didn’t want to bother anyone. And men who ignored warnings because they had a heightened sense of their own invincibility. I saw human nature.

I learned that, despite our best efforts, some falls will always happen in hospitals, just as they do outside of hospitals. As one physician told me, “Short of tying all patients down, we will never be able to totally eliminate falls from the hospital.’’

Does this mean we should stop tracking and reporting falls? Absolutely not. Tracking and analyzing them serves a purpose. Through better understanding, we will continue to make strides in prevention.

But it does mean we should track and report them differently. The state’s goal in producing this particular report is to shine a bright light in order to keep bad events from happening in hospitals. But it misleads the public to include on the list events that most experts agree cannot entirely be eliminated.

It is confusing, at best, to suggest there are 338 instances of things worthy of a scarlet letter, when the vast majority of those things are far more complicated. In the sphere of public reporting, sometimes too much information can be as problematic as too little.

Public confusion may not be the only problem. In a recent article in the New England Journal of Medicine, Dr. Sharon Inouye and her coauthors point out that too much public focus on falls may actually have unintended harmful consequences. It may cause hospitals to downplay the importance of patient mobility - getting them out of bed - which is critical to preventing other harmful complications.

I believe deeply in the benefits of public reporting. But in this age of transparency, the quality is as important as the quantity of the information on which we report. The DPH should not mix apples with oranges. The public will be far better served by pursuing a different approach to reducing hospital falls.

Douglas S. Brown is senior vice president and general counsel of UMass Memorial Health Care in Worcester.