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Overview and Implications

Evidence from the Canadian Adverse Event Study, indicates that adverse events classified as 'Other', including burns and falls was the sixth leading cause of an adverse event in Canada (Baker, Norton, et al, 2004).


A fall is defined as: an event that results in a person coming to rest inadvertently on the ground or floor or other lower level, with or without injury. This would include an unwitnessed fall where the client is able/unable to explain the events but there is evidence to support that a fall has occurred.

A fall injury is defined as an injury that results from a fall, which may or may not require treatment. The injury can be temporary or permanent and vary in the severity of harm (Safer Healthcare Now! Falls Getting Started Kit, 2013).

Falls occur due to a loss of balance or an inability to recover balance. A range of risk factors (>400) have been identified as influencing whether individuals are likely to fall. The BBSE MODEL of fall-related risk factors identifies biological (intrinsic), behavioural, social and economic and environmental (extrinsic) risk factors (for examples see Safer Healthcare Now! 2013, page 30). The more risk factors an individual has, the greater the risk of falling (Safer Healthcare Now! 2013; RNAO, 2012).

Falls may cause considerable physical harm, including fractures, soft tissue injuries, haematomas, lacerations and pressure sores due to subsequent immobility; as well as psychological distress such as fear of falling and humiliation and potentially resulting in chronic pain, loss of independence, reduced quality of life, and even death (Johal, 2009; Public Health Agency of Canada, 2014; Accreditation Canada, CIHI, CPSI, 2014). Clinical practice guidelines and systematic reviews highlight the importance of identifying a person's individual risk factors and providing multifactoral interventions to address those risk factors (AGS/BGS, 2012; Cameron et al, 2012; National Institute for Health and Care Excellence, 2013; Public Health Agency of Canada, 2014; Registered Nurses' Association of Ontario, 2012; Safer Healthcare Now! 2013; Royal College of Physicians, 2015).

Studies of hospital falls revealed that (Chari et al., 2013; Pulcins & Wan, 2004; Johal 2009; Maki et al., 2011; Deandrea et al., 2013):

  • Females were almost twice as likely to sustain fractures upon falling.
  • Walking increases the likelihood of a fall-related fracture as compared with falls from a static position.
  • Falls that were reported as having occurred during nursing shift change were associated with increased risk of fracture.
  • Patients not screened for falls risk on admission have a higher likelihood of falling.
  • Advancing age is a major contributing factor to falls.
  • Impaired control of gait and balance is widely recognized to be a major contributing factor.
  • History of falls, use of walking aids and disability are strong predictors of future falls.

Studies in acute care settings show that fall rates range from 1.3 to 8.9 falls per 1,000 patient days, with higher rates in units that focus on geriatric care, neurology, and rehabilitation (Oliver, 2010). Most hip fractures occur in the community, but nearly one in 1,000 seniors admitted to hospital fracture a hip during their stay (Pulcins & Wan, 2004). The repercussions both, medically, and financially, following a fall in hospital are immense. Patients suffering hip fractures after falls in hospital are frailer with impaired cognitive function and more co-morbidities than those suffering a fracture in the community. These patients have increased mortality, nearing 50 per cent within one year of the fall (Johal, 2009).


Burns to skin (or other organs) is a function of both temperature and duration. Even moderate heat applied for a long duration is capable of producing burns. There are three key conditions that predispose patients to burns including insensitivity to pain/temperature, unresponsiveness, or inability to communicate. In addition, impaired ability for the vasculature to help dissipate heat from the skin may predispose a patient to a burn (Patient Safety Solutions, 2010).

A search of patient safety reporting/alert systems revealed that the potential causes of accidental burns include:

  • A hot towel prepared in a plastic bag coming in contact with patient's body during bed-bath (Japan Council for Quality Health Care, 2010).
  • Use of a hot water bottle (Japan Council for Quality Health Care, 2010).
  • Fire and the use of Alcohol-based hand cleansers (New South Wales Department of Health, 2007).
  • Water temperature too hot during bathing (Japan Council for Quality Health Care, 2007).
  • Vaseline and treatment with oxygen (European Union Network for Patient Safety, 2011).
  • Heat therapy such as heating pads or hot packs (Data snapshot, 2009).
  • Food preparation and hot liquid spills (Data snapshot, 2009).
  • Burns Caused by the Tip of a Light Source Cable during Surgery (Japan Council for Quality Health Care, 2012).
  • Risk of skin-prep related fire in operating theatres (National Health Service Commissioning Board, 2012).

Fires on the operating field are rare events that should never happen, but do. They are dangerous not only to the patient but to the operating room (OR) team members as well (Clarke & Bruley, 2012).

Surgical fires that ignite in or around a patient during surgery are a real danger, and are especially devastating if open oxygen sources are present during surgery of the head, face, neck, and upper chest (ECRI, 2016).

In the fire triangle - heat, fuel and oxygen - each element must be present for a fire to start.

Hospital emergency rooms and operating rooms contain the three primary elements needed to ignite a fire:

  • An oxidizer (anesthesia products such as oxygen and nitrous oxide).
  • Fuel (surgical drapes, alcohol swabs, etc.).
  • An ignition source (lasers, electrosurgical devices such as a cautery knife, etc.).

A host of flammable materials are found in the surgical suite, from the wide range of alcohol-based prepping agents and linens such as drapes, towels, gowns, hoods and masks; to the multiple types of dressings, ointments and equipment and supplies used during surgery. Common ignition sources found in the OR are electrosurgical or electrocautery units (ESUs, ECUs); fiber optic light sources and cables; and lasers. In addition, ESUs, lasers and high-speed drills can produce incandescent sparks that can fly off the target tissue and ignite some fuels, especially in oxygen-enriched atmospheres. The surgeon and anesthesiologist control these elements and they are trained in hospital fire safety (Joint Commission, 2003).

The Pennsylvania Patient Safety Advisory reported that in 2007 an estimated 11.9 burns occur per 100,000 admissions in Pennsylvania. Based on their incident reporting system there were 224 reports of burns, two-thirds of which were thermal in nature. More than half the submitted burns were reported to have been caused by instruments or devices used in procedures, including cautery units, light sources (e.g. pulse oximetry), and cords for these devices. Nine per cent of the reported burns were attributed to therapeutic heat sources, such as heating pads or hot packs; a further five per cent were reported following magnetic resonance imaging procedures. Almost 14 per cent of reported burns were attributed to food preparation or distribution. These reports include hot liquid spills and handling hot containers (Data snapshot, 2009).

While exact numbers [of surgical fires] are not available, of the more than 23 million inpatient surgeries and 27 million outpatient surgeries performed each year, estimates - based on data from the US Food and Drug Administration (FDA) and ECRI, an independent non-profit health services research agency - indicate that there are approximately 100 surgical fires each year, resulting in up to 20 serious injuries and one or two patient deaths annually (Joint Commission, 2003). An oxygen-enriched atmosphere was a contributing factor in 74 per cent of all hospital fires. About 70 per cent of all surgical fires are started by electrosurgical tools that use a high-frequency electric current to cut tissue or stop bleeding. About 20 per cent of hospital fires are sparked by burrs, defibrillators, hot wires or light sources, while approximately 10 per cent are ignited by lasers (Lawyers and Settlements, 2012).


Asphyxia is severe hypoxia leading to hypoxemia and hypercapnia, loss of consciousness, and, if not corrected, death. There are many circumstances that can induce asphyxia; some of the more common causes are drowning, electrical shock, aspiration of vomitus, lodging of a foreign body in the respiratory tract, inhalation of toxic gas or smoke, and poisoning (Mosby's Medical Dictionary, 2009). A search of patient safety reporting/alert systems revealed that the potential causes of iatrogenic asphyxia include:

  • Restraints (Joint Commission, 1998; Registered Nurses' Association of Ontario, 2012).
  • Positional asphyxia occurs when the body's position interferes with respiration and was found to occur when individuals were placed in a position that did not allow adequate breathing. Most often a prone position or restrictive or confining position, a simple flexion of the head onto the chest, a partial or complete external airway obstruction, or neck compression (Mohr et al, 2003).
  • Strangulation (Joint Commission, 1998, Registered Nurses' Association of Ontario, 2012).
  • Bed rails and bed entrapment - asphyxiation was caused by one of the following: being caught between the bed rail and the mattress; being caught between the head board and the bed rail; the patient's head becoming stuck in the bed rail; or being strangulated by a vest restraint between the rails (Joint Commission, 2002).
  • Accidental ingestion of fluid/food thickening powder (NHS, 2015).
  • Traumatic intubation (Pazannin et al., 2008).
  • Factors that may contribute to an increased risk of death from restraints, root causes for restraint-related asphyxia or bed rail related asphyxia may be accessed in the CPSI Global Safety Alerts (Healthcare related asphyxiation).

A literature search did not reveal data regarding the incidence of healthcare associated asphyxia; however, a 1998 JCAHO Sentinel Event Alert that reviewed 20 restraint-related deaths found that 40 per cent of deaths were caused by asphyxiation. The extent to which restraints can be classified as therapeutic interventions is questionable: their efficacy as therapeutic measures has not been empirically demonstrated in outcome studies (Mohr, 2003).

Although physical intervention is considered by most in healthcare security to be the method of last resort, sometimes hospital employees have no alternative but to use this approach on someone who becomes a danger to themselves or others. Awareness of restraint-related positional asphyxia and how to avoid positioning that could restrict breathing is of critical importance (Schubert, 2011). When restraint use is unavoidable, the least restrictive form of restraint is used for the shortest duration of time for avoidance of harm to self/others; restraint use is temporary and alternatives must continue to be considered (RNAO, 2012).


To prevent in-hospital patient injury such as fractures, dislocations, burns, asphyxia etc. from occurring in patients.