UNO Researchers Aim to Prevent Patient Falls

OMAHA – Researchers from the University of Nebraska at Omaha (UNO), in collaboration with faculty from the University of Nebraska Medical Center (UNMC), have published a report that shows millions of emergency room visits a year can largely be prevented if caregivers spent as little as 10 minutes on addressing the causes and solutions to patient falls.

This week, a paper by UNO Department of Psychology professors Roni Reiter-Palmon, Victoria Kennel and Joseph A. Allen, along with UNMC researchers Katherine J. Jones and Anne M. Skinner, was published in the September issue of the Journal of Occupational and Organizational Psychology.

The paper, titled “Naturalistic decision making in after-action review meetings,” analyzed the addition of a “post-fall huddle” after-action meeting between staff members to 17 hospitals in rural Nebraska. Results showed that holding these meetings, which include members from multiple hospital departments, including nurses, doctors and pharmacists, can decrease the number of falling injuries by as much as 20 percent and reduce falling severity by approximately 30 percent.

The study also looked to see if there was any change in the types of errors that staff members agreed were responsible for the fall: either task directions, personal judgment or coordination of staff members. Results showed that judgment errors were consistently most at fault but the addition of post-fall huddles helped decrease task-related errors.

“There is never just one cause for a fall,” explained Reiter-Palmon, the paper’s lead author and director of UNO’s Industrial/Organizational psychology graduate program. “It could be due to a change in medication that wasn’t communicated to staff, or a nurse member forgetting to put the bed rails up. However, calling attention to those errors allows staff members to keep those issues fresh in their mind and more cautious about how they deal with patients who are at-risk for falls.”

According to a 2013 report from the Centers for Disease Control, there can be as many as 2.3 million nonfatal fall injuries each year just among older adults with as many as 600,000 of them resulting in hospitalizations.

These hospitalizations can not only result in additional costs to the hospital and to the patient, or the patient’s families, but a particularly dangerous fall could injure someone badly enough to require being moved to an assisted living facility.

“This study has important practical benefits to smaller, rural hospital or care facilities that don’t have the same level of funding or staff as similar facilities found in major cities,” Reiter-Palmon explained. “Spending just 10 minutes discussing where the errors occurred between departments can save money and even lives.”

Reiter-Palmon points out that the addition of post-fall huddles really only work if the staff members believe they hold value. Because of that, the overall concept is made flexible and adaptable to any staff size or type.

“In essence, it doesn’t matter how large the organization is, what matters is that you have a way to foster interdisciplinary communication,” she said.

Additionally, the study finds that even though there was a decrease in fall severity in utilizing the post-fall huddles, there is still work that organizations can do to help determine and recognize the causes of falls.

Reiter-Palmon adds that a follow up study with the participating hospitals is planned for the near future, as well as expanding the study to larger hospitals in more urban environments.

Questions about the study? Please contact Charley Reed, UNO media relations coordinator, at unonews@unomaha.edu or 402.554.2129.

About the University of Nebraska at Omaha

Located in one of America’s best cities to live, work and learn, the University of Nebraska at Omaha (UNO) is Nebraska’s premier metropolitan university. With more than 15,000 students enrolled in 200-plus programs of study, UNO is recognized nationally for its online education, graduate education, military friendliness and community engagement efforts. Founded in 1908, UNO has served learners of all backgrounds for more than 100 years and is dedicated to another century of excellence both in the classroom and in the community.

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