Modeling of adult patient falls and the repercussions to Nursing as a second victim.
Deise Vacario de Quadros, Ana Maria Müller de Magalhães, Priscila Wachs and 3 others
PMID 35920541WHAT IT FOUND
Twelve moderate to severe hospital falls were modeled with nurses' accounts: absent companions, sedating or strength-changing drugs, night shift, and inability to accompany movement were described as recurring problems.
Nurses reported guilt and fear after patient harm.
Key findings
01Of 447 recorded falls, 242 were in adult inpatient units and 12 had moderate to severe harm; nine of the 12 occurred at night.
02The modeled cases described variability when companions were absent, patients had drugs affecting sleep, blood pressure, or muscle strength, patients' general condition changed, or staff could not accompany movement.
03Nursing workers described guilt, fear, anguish, impotence, and trivialization after falls that harmed patients.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study analyzed 12 falls and interviewed nursing workers selected from five units in a university hospital, so the findings are context-specific and may not apply to other settings. It did not compare outcomes with and without a prevention change, so it cannot show that companions, medication review, night-shift assistance, or process modeling reduced falls. Patient data came from records and notifications, not from patients or families directly, and the emotional findings came from nursing workers' accounts rather than measured patient outcomes. Of 21 selected professionals, one declined and one could not participate, and the paper does not state how many interviews were ultimately analysed. The paper is qualitative and descriptive; its themes are not effects, and the modeling did not test a clinical intervention.
Declared interests
The supplied text does not report funding or conflicts of interest.
The easy way to misread this
Do not read the modeled factors as proven causes of falls or as evidence that adding companions, changing medications, or staffing the night shift prevents falls. This paper described 12 falls and nurses' accounts; it did not test any intervention against a control group.