A High Fall Risk Patient Perspective-Reducing Safety Challenges in an Acute Care Hospital.
Caglayan Yasan, Gabriella Pretto, Patricia Burton
PMID 39946289WHAT IT FOUND
Seven inpatients who fell described not receiving fall brochures, misunderstanding alert signs and low-low beds, waiting on call bells, bathroom supervision gaps, and nurse-patient communication breakdown.
Key findings
01Five patients said they had not received a fall prevention brochure, and audit data showed only 17.5% of patients received one.
02Only 58% of high fall risk patients had an alert sign displayed, and several patients did not know why they had one.
03Five patients fell walking to the toilet, in the bathroom, or near the sink, and delayed call bell responses led some to ambulate without help.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
Only seven of 30 suitable patients agreed to interviews, so the findings reflect a small group. The study took place in one medical ward over a 4-month period, so it may not apply to other wards or hospitals. It was not a trial of fall prevention strategies, so it cannot show whether alert signs, low-low beds, brochures, bathroom supervision, or walkers reduced falls. Administrative data and nurse audits did not record patient perspectives or call bell response times, and some patient reports contradicted the database. Interviewed patients were cognitively intact and English speaking, and no interpreter was required, so the findings may not apply to patients with cognitive impairment or language needs.
Declared interests
The authors declare no conflict of interest.
The easy way to misread this
Do not read this as proof that alert signs, low-low beds, or brochures prevent falls. It reports seven patients' perspectives and audit data from one ward, not a tested effectiveness outcome.