Pt. Falls

[Nursingluv101]

Last night I had a pt. fall that literally scared the crap out of me. I felt like such a bad nurse, which I know I'm a good nurse, yet anything something happens like that I take it personally. My guy came in for a syncopal episode, I charted he was unsteady and, and a fall risk. I made sure he had his slip guard socks. Call light in reach and bed alarm on earlier. He basically refused to use the urinal because he could not urinate sitting or lying and wanted to walk to rest room. Pt. was starting to feel better so I assisted him to the rest room 2 times. Some time in between the X-ray and maybe going to bathroom again the bed alarm did not get turned back. I think the ER might have forgot to. When he got back X-ray. I also had a lady who was peeing every 20 minutes. It seemed like and was going on and off the bedpan. I literally just got done putting my other pt. off the bedpan. Went to sit down and chart. Heard a bang, I ran into room and there was my pt. laid out on the ground bleeding from his head. Had a lac. Luckily no head bleed or major

Complications. First thing the charge said to me was why wasn't the bed alarm on, I told her, I don't know if I forgot to turn it back on or what. I realized later the last person to put the pt back in bed was the ER tech I felt absolutely horrible, for not reassessing the bed alarm, when I placed the pt. back on cardiac monitors, and I felt like every positive thing or good nursing I did just went out the window. I seriously wanted to cry. I never thru the tech under the bus because in all actuality it's my responsibility. It was horrible I was all flustered and upset. I have came from a trauma unit, and also have dealt with multiple critical pts and fragile situations, but this really upset me. Any suggestions on preventing falls and not taking stuff like this so personal.

[Anonymous865]

I'm not a nurse, so I can't speak to your situation as another nurse. If I had been the patient who fell or a family member of the patient who fell, this is how I would view the incident. -

The facility would be to blame for the fall in the following cases:

- The patient called more than once for assistance going to the bathroom. No one came, so the patient felt they had to get up without assistance.

- The patient fell because someone had spilled some liquid or dropped some trash on the floor and hadn't cleaned it up.

- The patient fell because the hospital hadn't installed grab bars in the bathroom or hallways (or in other places the prudent hospital would have installed them.)

- The patient fell because of faulty hospital equipment.

- The patient was not aox3 and left alone without steps being taken to prevent them from getting up unassisted.

- The patient fell because of poor lighting.

- The patient fell because of poorly marked changes in the floor like steps in unexpected places.

Nothing in your description of the incident indicates that any of these things were a factor in the patient's fall. I DO NOT SEE HOW YOU ARE TO BLAME FOR THE PATIENT"S FALL.

I know that hospitals and CMS view falls in the hospital as "never events." It is unrealistic to think that no one is ever going to fall in a hospital. The only way to prevent all falls is to never allow a patient or visitor to move. This could be accomplished by meeting each patient at their car and transferring them from their car to a wheelchair. You can't let them transfer themselves to the wheelchair because they might fall during the transfer. You can't let staff transfer the patient because they might drop the patient during the transfer. You could use equipment to transfer the patient, but it might malfunction and injure the patient.

OK. Let's forget about how we are going to get the patient to their room. Let's assume somehow we got the patient in their hospital bed without falling. The only way to insure they don't fall is to put every patient in diapers and tie them down to their bed. Even with bed alarms a patient could potentially get up and fall before a staff member could get there to prevent their fall. Clearly that solution could harm the patient because of deconditioning, DVTs, pressure sores, etc.

Obviously someone is to blame in this situation for not following hospital policy and activating the bed alarm (if that is hospital policy.)

You are not to blame for the patient's fall. The patient is the only one to blame for the fall. Thankfully the patient was not seriously injured.

Even if the alarm had been enabled, the patient could have fallen before someone could have reached the room. The only difference would be that everyone could say they followed policy.

When a negative event occurs it is wise to examine the root cause of the event and try to prevent it from happening again. There is nothing to be gained from beating yourself up over this. You are not a "bad" nurse, because an adult made a decision that resulted in their fall. Adults are allowed to do that.

[kaylee.]

I salute the support that pp gave, but unfortunately in this situation it always comes back to the nurse not making sure the bed alarm was back on and they were safely in their bed after xray.

I know this bc it happened to me once. I was a new grad and had gotten report and forgot to make sure the alarm was on. The day nurse had him off the alarm her whole shift. Just so happens he climbs out and falls 30 min into my shift, so its all on me.

I had another patient on wall suction and had an order to unhook to use the bathroom. Was so vigilant all shift about reattaching it. Then at the end someone walking by helped her to the br and didnt rehook her. So the charge saw and got really upset with me. Yes, i was just in there and there was no way to avoid this without going in every 10 min. Unfortunately it always comes back to us not checking and rechecking.

I feel u op. It happens!