Oliver D, Killick S, Even T, Willmott M
School of Health and Social Care and Institute of Health Sciences, University of Reading, London Road Campus, Reading, UK.
Qual Saf Health Care. 2008 Dec;17(6):431-6. doi: 10.1136/qshc.2007.024703.
Accidental falls are very common in older hospital patients -- accounting for 32% of reported adult patient safety incidents in UK National Health Service (NHS) hospitals and occurring with similar frequency in settings internationally. In countries where the population is ageing, and care is provided in inpatient settings, falls prevention is therefore a significant and growing risk-management issue. Falls may lead to a variety of harms and costs, are cited in formal complaints and can lead to claims of clinical negligence. The NHS Litigation Authority (NHSLA) negligence claims database provides a novel opportunity to systematically analyse such (falls-related) claims made against NHS organisations in England and to learn lessons for risk-management systems and claims recording.
To describe the circumstances and injuries most frequently cited in falls-related claims; to investigate any association between the financial impact (total cost), and the circumstances of or injuries resulting from falls in "closed" claims; to draw lessons for falls risk management and for future data capture on falls incidents and resulting claims analysis; to identify priorities for future research.
A keyword search was run on the NHSLA claims database for April 1995 to February 2006, to identify all claims apparently relating to falls. Claims were excluded from further analysis if, on scrutiny, they had not resulted from falls, or if they were still "open" (ie, unresolved). From the narrative descriptions of closed claims (ie, those for which the financial outcome was known), we developed categories of "principal" and "secondary" injury/harm and "principal" and "contributory" circumstance of falls. For each category, it was determined whether cases had resulted in payment and what total payments (damages and costs) were awarded. The proportions of contribution-specific injuries or circumstances to the number of cases and to the overall costs incurred were compared in order to identify circumstances that tend to be more costly. Means were compared and tested through analysis of variance (ANOVA). The association between categorical variables was tested using the chi-square test.
Of 668 claims identified by word search, 646 met inclusion criteria. The results presented are for the 479 of these that were "closed" at the time of the census. Of these, 290 (60.5%) had resulted in payment of costs or damages, with the overall total payment being 6,200,737 pound (mean payment 12,945 pound). All claims were settled out of court, so no legal rulings on establishing liability or causation of injury are available. "Falls whilst walking;" "from beds or trolleys" ("with and without bedrails applied") or "transferring/from a chair" were the most frequent source of these claims (n = 308, 64.2%). Clear secondary contributory circumstances were identified in 190 (39.7%) of closed claims. The most common circumstances cited were "perioperative/procedural incidents" (60, 12.5%) and "requests for bedrails being ignored" (54, 11.3%). For primary injuries, "hip/femoral/pelvic fracture" accounted for 203 (42.4%) of closed claims with total payments of 3,228,781 pound (52.1% of all payments), with a mean payment 15,905 pound per closed case. A "secondary" contributory circumstance could be attributed in 133 (27.8%) of cases. Of these, "delay in diagnosis of injury," "recurrent falls during admission" and "fatalities relating to falls" were the commonest circumstances (n = 59, 12.2%).
Although falls are the highest volume patient safety incident reported in hospital trusts in England, they result in a relatively small number of negligence claims and receive a relatively low total payment (0.019% in both cases). The mean payment in closed claims is also relatively small. This may reflect the high average age of the people who fall and difficulty in establishing causation, especially where individuals are already frail when they fall. The patterns of claims and the narrative descriptions provide wider lessons for improving risk-management strategies. However, the inherent limitations and biases in the data routinely recorded for legal purposes suggest that for more informative research or actuarial claims analysis, more comprehensive and systematic data to be recorded for each incident claim are needed.
在老年住院患者中，意外跌倒非常常见——在英国国民医疗服务体系（NHS）医院报告的成年患者安全事件中占32%，在国际上的住院环境中发生频率也类似。在人口老龄化且提供住院护理的国家，预防跌倒因此是一个重大且日益重要的风险管理问题。跌倒可能导致各种伤害和成本，在正式投诉中被提及，并可能引发临床过失索赔。NHS诉讼管理局（NHSLA）的过失索赔数据库提供了一个新机会，可系统分析针对英格兰NHS组织提出的此类（与跌倒相关的）索赔，并为风险管理系统和索赔记录吸取经验教训。
描述与跌倒相关索赔中最常提及的情况和伤害；调查“已结案”索赔中财务影响（总成本）与跌倒情况或伤害之间的任何关联；为跌倒风险管理以及未来跌倒事件数据收集和由此产生的索赔分析吸取经验教训；确定未来研究的重点。
在NHSLA索赔数据库中对1995年4月至2006年2月进行关键词搜索，以识别所有明显与跌倒相关的索赔。经审查，如果索赔并非由跌倒导致，或仍为“未决”（即未解决），则将其排除在进一步分析之外。从已结案索赔（即财务结果已知的索赔）的叙述性描述中，我们制定了“主要”和“次要”伤害/损害类别以及跌倒的“主要”和“促成”情况类别。对于每个类别，确定案件是否导致付款以及判给的总付款（损害赔偿金和费用）是多少。比较特定伤害或情况对案件数量和所产生的总成本的贡献比例，以确定往往成本更高的情况。通过方差分析（ANOVA）比较并检验均值。使用卡方检验检验分类变量之间的关联。
通过关键词搜索识别出的668项索赔中，646项符合纳入标准。呈现的结果是针对在普查时“已结案”的其中479项。其中，290项（60.5%）导致支付了费用或损害赔偿金，总支付金额为6,200,737英镑（平均支付12,945英镑）。所有索赔均在庭外和解，因此没有关于确定伤害责任或因果关系的法律裁决。“行走时跌倒”；“从病床或推车（无论是否使用床栏）”或“从椅子转移/跌倒”是这些索赔最常见的来源（n = 308，64.2%）。在190项（39.7%）已结案索赔中确定了明确的次要促成情况。最常提及的情况是“围手术期/手术过程事件”（60项，12.5%）和“对使用床栏的请求被忽视”（54项，11.3%）。对于主要伤害，“髋部/股骨/骨盆骨折”占已结案索赔的203项（42.4%），总支付金额为3,228,781英镑（占所有支付金额的52.1%），每个已结案案件的平均支付为15,905英镑。在133项（27.8%）案件中可归因于“次要”促成情况。其中，“伤害诊断延迟”、“住院期间反复跌倒”和“与跌倒相关的死亡”是最常见的情况（n = 59，12.2%）。
尽管跌倒是英格兰医院信托机构报告的数量最多的患者安全事件，但它们导致的过失索赔数量相对较少，总支付金额也相对较低（两种情况均为0.019%）。已结案索赔的平均支付金额也相对较小。这可能反映了跌倒人群的平均年龄较高以及确定因果关系存在困难，尤其是当个体跌倒时已经很虚弱的情况。索赔模式和叙述性描述为改进风险管理策略提供了更广泛的经验教训。然而，出于法律目的常规记录的数据中固有的局限性和偏差表明，为了进行更有信息量的研究或精算索赔分析，需要为每个事件索赔记录更全面、系统的数据。
