Mon August 12, 2013
Caution: Patients Falling At Washington Hospitals
Medical mistakes are a leading cause of death and injury in America. One of the most frequent mishaps in Washington hospitals: patients who fall. A fall in a hospital can lead to serious complications, even death. Medical experts say that kind of fall should never happen.
One Small Step, One Big Fall
Helen Funston lies on her back in a darkened room. She pushes her shoulder down into physical therapist Stella In’s hand until she gasps with pain.
Funston tells In the pain is an eight out of 10.
“It’s achy, kind of like a stabbing with something hot,” she says.
Funston is a retired parts buyer for Boeing with a history of spinal problems. This time, 69-year-old Funston is getting therapy for an injury she says she got while she was already in a hospital.
She was recuperating from spinal surgery at Swedish Medical Center’s Cherry Hill campus in Seattle, with a newly installed plate in her neck. She says she hit her call button for a nurse to come help her go to the bathroom. But after a half hour of waiting, and no nurse, she decided to get up and go to the bathroom unassisted.
She didn’t get far. With her first steps out of bed, she slipped and fell.
“I don’t remember a lot,” Funston says. “I apparently hit my head straight down.”
The plate that she’d just had put in her neck was knocked out of place. Funston had to have her neck surgery redone and have additional spinal surgery on her back.
“They put in rods and plates and whatnot because the original plate, when I fell, had cracked my vertebrae.”
According to hospitals’ own reports collected by the Washington state Department of Health, hospital falls injure or kill patients like Helen Funston a few dozen times a year. That’s out of hundreds of thousands of hospital visits statewide. Last year, according to health department data, three Washington hospitals tied for having the most falls: Harborview Medical Center in Seattle, Providence Medical Center in Everett and St. Joseph Hospital in Bellingham each reported seven patients being injured from falls.
While serious falls are infrequent, safety experts call them “never events” — things that should never happen inside the protective embrace of a hospital.
State law requires hospitals to report their mishaps. According to those reports, serious falls are on the rise in Washington’s hospitals.
Federal privacy law forbids Swedish officials from talking about any individual patient’s care.
“But, certainly, it’s not our expectation or standard that someone would wait 30 minutes for someone to answer a call light,” said June Altaras, chief nursing officer at Swedish Health Services.
Altaras says Swedish carefully assesses all patients for their risk of falling. They look at things like what medications or sedatives they’re on, are they disoriented? Do they have a history of falls?
Any patients at risk of falling have bed alarms that go off as soon as the patient rises from the bed.
“We really, really want you never to get out of bed without calling us,” says Altaras.
Since a patient can fall in the blink of an eye, and hospital hallways are filled with a cacophony of beeps and buzzers, the bed alarm makes an unmistakable sound: the tune of “Mary Had A Little Lamb.”
“It gets your attention and people all know what that means,” says Altaras. “So you’re able to get to the room before the patient’s feet are able to hit the floor, so to speak.”
Helen Funston says there was no alarm on her bed. Since her fall nearly three years ago, she says she hasn't had a day without pain. She’s seeking a $1.3 million settlement from Swedish.
Altaras says Swedish revamped its fall-prevention programs in 2011.
Falling In Auburn
Funston may be lucky that nothing worse happened.
At least two patients have died after falling at Auburn Regional Medical Center. The south King County hospital has reported more falls over the past six years of state data gathering than any other hospital in Washington. Auburn is the state’s 32nd largest hospital.
The family of John Basic of Renton received an undisclosed settlement from Auburn last year. The retired Boeing engineer died a month after falling at Auburn in 2008, where he’d been receiving a routine treatment on a vein in his arm.
“While he was coming out of the full effects of anesthesia, he fell off the recovery table, struck his head and suffered a brain injury,” says Dan Hannula of Tacoma, the attorney who represented the family.
Basic was transferred to Harborview Medical Center for brain surgery. After a month on a ventilator there, he died of a lung infection. He was 77. Hannula says:
Falls like this should not occur in hospitals. This is an injury that is 100 percent preventable. Once you have surgery and you’re in that process of recovering from the surgery and the anesthesia, you have to be protected at all times. I don’t think that’s too much to ask from a hospital.
Until last October, Auburn Regional Medical Center was one of the few for-profit hospitals in Washington state. The nation’s fourth largest for-profit hospital chain, Universal Health Services, operated it.
In addition to Auburn’s frequent falls, other measures suggest problems with the quality of care the hospital provided under UHS:
- Auburn had, by far, the state’s worst patient satisfaction rating, according to the most recent patient surveys conducted by the Centers for Medicare & Medicaid Services in 2011-2012.
- In July, Consumerreports.org gave Auburn one of the state’s worst surgery safety scores, based on data collected in 2011 and before.
- Auburn is currently facing the stiffest federal penalties of any hospital in Washington state for having poor “readmission” rates over the past 3 years – unusually large numbers of patients had to be readmitted to the hospital shortly after being discharged.
Universal Health Services spokesperson Mary Ann Ninnis in Pennsylvania did not respond to KUOW’s requests for comment on Auburn’s safety record.
In October, the nonprofit MultiCare bought Auburn Regional Medical Center for $98 million. Officials with the Tacoma-based chain said they knew that the quality of care at Auburn wasn’t up to their standards when they bought it. But the specifics were a bit of a mystery.
“What surprised me was working with a for-profit organization and what we were allowed and not allowed to have access to,” says Dr. Lester Reed, the vice president in charge of patient safety at MultiCare. He says UHS officials wouldn’t disclose their safety record or procedures to MultiCare.
“It was very hard to even have meetings with them because they were limiting on the number of meetings that were even possible,” says Reed.
As soon as the purchase was complete, MultiCare sent a safety analyst to study how the hospital ran. MultiCare officials then upgraded equipment, retrained staff and changed safety procedures. They focused on three areas: falls, infections and hand hygiene.
Among other changes since MultiCare took over, patients at risk of falls at Auburn now stand out from the rest, with special yellow wristbands and yellow grippy socks.
In less than a year, the hospital’s rate of falls has dropped by more than two-thirds, according to Reed.
“That’s phenomenal,” he says. “I’m personally incredibly proud of what has happened here.”
Auburn’s safety overhaul also included adding more than 100 new jobs.
“That’s been a real benefit. It makes our job so much easier,” says emergency room nurse Joyce Sward. She has worked at Auburn for 35 years, under both UHS and MultiCare ownership.
Auburn sees a lot of older patients and psychiatric patients, both of whom tend to be higher risk for falling. Sward says the new staff include more psychiatric specialists in the ER.
“That was something we sorely needed and never got, and now we do.”
Back at Swedish, the Seattle hospital chain is investing in a brand-new fleet of hospital beds. All of them will have “Mary Had A Little Lamb” alarms built in to detect when a patient’s body weight is no longer pushing down on the bed. So everywhere that patients rise, alarms are sure to go.