Fall Prevention: When Safe Patient Handling Goes Wrong


When safe patient handling procedures fail, the outcome can be devastating for both the patient and the facility. The Agency for Healthcare Research and Quality (AHRQ) estimates up to 1 million hospital patients fall each year.


According to the Joint Commission, the total facility cost for one fall with injury is approximately $14,056. LHA Trust Funds found that slip, trip, and fall claims closed between 2016 and 2020, cost an average of $21,075.

This month’s claim explores what happens when safe patient handling procedures fail but do not directly cause patient injury.


The Incident: Stretcher Struggles

A 76-year-old female underwent a total knee replacement. Three days after surgery, she was discharged to an extended care facility for post-op therapy.

Upon arrival at the extended care facility, the ambulance attendants failed to make sure that the legs of the stretcher were secured in the locked position. When the stretcher was placed on the ground, the legs of the stretcher collapsed, causing the stretcher and patient to drop to the ground. The patient did not fall off the stretcher and hit the pavement.

The patient complained of head and back pain and exhibited some shortness of breath. Due to her symptoms, she was brought back to the hospital’s emergency room. The patient was then admitted for observation based on abnormal - but not critical - vital signs and a suspicious chest x-ray.

Follow-up care revealed a pulmonary embolus because of postoperative deep vein thrombosis (DVT). Because of a quick diagnosis and prompt treatment of the DVT, the patient had no serious complications. She was discharged back to the extended care facility three days later in good condition.


The Claim: Determining Causation

A medical malpractice complaint was filed alleging that the “dropping” incident caused the DVT. A Medical Review Panel stated that the ambulance attendants deviated from the appropriate standard of care for both not making sure the stretcher legs were securely locked and for not mentioning the “drop” in their report.

However, the panel unanimously found that a DVT is a well-known risk associated with knee surgery. They did not find the “dropping” incident either caused or contributed to the DVT’s development.

A post-panel lawsuit was filed. Both the plaintiff and the defendant filed Motions For Summary Judgment on the issue of causation. The judge granted the defendant’s motion and the case was dismissed with no appeal.


Preventing the Risk: Investigation

How many times do incidents like this occur? An adverse event of this nature requires investigation to determine the root cause(s) of the situation.

Investigation and subsequent actions are determined by the organization responsible for the ambulance company. If the ambulance service is owned by your facility, the program and employees should be incorporated into organizational plans. It should also be included in the quality, risk, compliance and education programs.

If your facility does not own the ambulance service and a similar incident occurs, the owner of the ambulance service is responsible for the investigation. The history of the accident should also be documented in the hospital record.


Root Cause Analysis: Best Practices

If we did a root cause analysis on this event, what types of things do you think might be discovered? Best practices that should be kept in mind as your organization moves through the process include:

  • Equipment Malfunction
    Is this a new stretcher? Was the stretcher defective? Why didn’t the legs lock when it was removed from the ambulance? Equipment involved in an accident should be removed from service and investigated before continuing use. Do not allow the manufacturer to look at it until the insurance carrier agrees. Make sure there was no recall on this equipment.
  • Equipment Inspection
    Inspections of this type of equipment for proper operation should be done regularly and documented/tagged. This applies if the ambulance were hospital owned and operated.
  • Training
    Were the staff member(s) trained on this type of equipment? Is this a different equipment brand than what is normally used?
  • Occurrence Reporting
    After this incident, an occurrence report should have been completed and a root cause analysis (RCA) written. The responsibility for this step falls upon those who had custody of the patient at the time of the occurrence – the ambulance company. Was the ambulance owned by the facility or an independent organization? In either case, this step is vital.
  • Documentation
    What happened should have been documented in the run report, a medical report made by EMS employees documenting the status and history of a patient.

The paramedic in question should have documented the incident just as other healthcare professionals would document any other accident. However, it is not clear how much training EMS employees receive in creating appropriate documentation. If the ambulance service is owned by your facility, include EMS in documentation training. As mentioned above, the history of the accident should also be documented in the hospital record.

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