Overview and Implications
According to the report
Never Events for Hospital Care in Canada, three of the fifteen never events are associated with patient trauma during hospitalization:
- Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area,
- Patient death or serious harm due to an accidental burn and
- Patient death or serious harm as a result of transport of a frail patient, or patient with dementia, where protocols were not followed to ensure the patient was left in a safe environment (Canadian Patient Safety Institute 2015)
Additionally, 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 a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, the ground or other surface (e.g. mat). Injuries sustained by visitor slips, trips, and falls can result in significant harm and costs. Falls can be classified as:
Anticipatory (patients exhibit clinical signs that contribute to increased falls risk),
Unanticipated (physiological falls that cannot be predicted before first occurrence) and
Accidental (result of mishaps)
Anticipated falls can be prevented through screening for falls risk factors, communication and in-depth assessment and implementation of targeted prevention strategies (HIROC 2016).
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. The more risk factors an individual has, the greater the risk of falling (Safer Healthcare Now! 2013; RNAO 2017).
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).
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). Research shows that close to one-third of falls can be prevented (Ganz, et al. 2013/2018).
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).
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.)
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).
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).
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; (Registered Nurses' Association of Ontario 2017).
- Positional asphyxia. This occurs when body position prevents adequate gas exchange, such as from upper airway obstruction or a limitation in chest wall expansion (Segen's Medical Dictionary 2012).
- Strangulation (Registered Nurses' Association of Ontario 2012).
- Rail entrapment - when caught, stuck, wedged, or trapped between the mattress/bed and the bed rail, between bed rail bars, between a commode and rail, between the floor and rail, or between the headboard and rail (U.S. Food and Drug Administration 2018).
- Accidental ingestion of fluid/food thickening powder (NHS 2015).
- Traumatic intubation (Pazannin et al. 2008).
To prevent in-hospital patient injury such as fractures, dislocations, burns, asphyxia etc. from occurring in patients.
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