2021_Book_TextbookOfPatientSafetyAndClin

17 Patient Safety in Internal Medicine
Table 17.10 Risk factors for falls in hospitalized patients
[90]
Age >85 years
Male sex
Recent fall
Gait instability
Agitation and/or confusion
New urinary incontinence or frequency
Adverse drug reactions (especially with psychotropic
drugs)
Neurocardiovascular instability (usually orthostatic
hypotension)
Table 17.11 External and internal factors associated
with falls [182]
External factors
Prior falls
Visual impairment
Stroke
Joint diseases (i.e.,
arthritis/arthrosis)
Orthostatic hypotension
Acute diseases needing
hospitalization
Gait instability
Cognitive impairment
Urinary incontinence
Drugs (impacting on
blood pressure, glycemia,
and gait)
Internal factors
Physical restraint
Unsuitable footwear
Unsuitable ambulation
aids
Environmental factors
(stairs, bathtub with no
support, poor lighting,
etc.)
medications (Table 17.12) or health problems
increasing the risk of falls, unsuitable footwear,
and visual impairment. There is a high-quality
evidence that multicomponent interventions can
reduce risk for in-hospital falls by as much as
30% [91]. The optimal bundle is not clearly
defined but relevant components are: patients risk
assessment, patient and staff education, bedside
signs and wristband alerts, footwear advice,
scheduled and supervised toileting, and medication
review [91]. In particular, patients’ education
should include exhaustive oral and written information
to patients/caregivers —taking into consideration
the patient’s ability to understand and
retain this information— about (1) patient’s risk
factors for falls; (2) how to call the nurse as well
as when to ask for help before moving from or
233
around the bed; (3) when and how to raise bed
rails; (4) other interventions aimed at addressing
individual risk factors.
Harms due to interventions have not been
studied systematically, but they may include an
increased use of restraints and sedatives and
decreased patients’ mobilization [91].
Key factors for a successful implementation
of such multicomponent interventions include:
leadership support, engagement of frontline in
the design of the intervention, multidisciplinary
committee, pilot-testing the intervention, and
changing nihilistic opinions about falls [91].
Wandering. It refers to two different, sometimes
associated, behaviors: (1) the tendency of
nursing home residents or hospital inpatients to
persistently walk, spatial disorientation, or a
combination of both [92]; (2) a situation in which
a subject with dementia has become lost in the
community. Although not all subjects with cognitive
impairment exhibit wandering behavior, all
are at risk for wandering away from the care setting
and becoming lost [93].
The first measure to prevent wandering consists
of an accurate assessment of patient’s diseases
impairing cognition such as Alzheimer’s
disease, fronto-temporal dementia, Lewy body
disease, multi-infarct dementia, and delirium, on
admission. In such cases, supervision is pivotal to
reduce wandering-related problems [94] and
should allow an immediate identification of
patients at risk (e.g. through colored wristbands,
armbands, or gowns), strategies providing an
intensive surveillance (i.e. rooms close to the
nursing station so that can be easily controlled by
nurses and patients cannot go out without passing
through it), and engagement of family members.
This latter can play an important role during hospitalization
as a familiar voice or face can
decrease fear and agitation of the patients, thus
reducing the patient’s willing of wandering.
Other strategies may include the avoidance of
rooms near elevators, stairs, or exit doors as
patients with cognitive impairment tend to
respond to what they see around them. Placing
clothes, shoes, and suitcases out of the patient’s
view can help as well. Finally, electronic monitoring
could represent a big help, installed in the