21 July 2010
The annual National Falls Awareness Week took place during 21st -25th June 2010 and the National Patient Safety Agency (NPSA) took this opportunity to remind NHS organisations across England and Wales of the guidelines for reducing patient falls. The ‘How to’ Guide for Reducing harm from falls1 produced by the NPSA and the Patient Safety First campaign is aimed at supporting managers and teams involved in leading and implementing changes to reduce harm from falls.
The authors of The ‘How to’ Guide for Reducing harm from falls1 make several recommendations to leadership and front line staff in NHS organisations to support a reduction in falls. These include:
- Establishing a falls prevention group with Board leadership
- Learning from previous fall experiences
- Training and developing staff in falls prevention
- Creating a safe environment
- Having post-fall protocols for care and secondary prevention in place
- Providing in-depth assessments and having a multifaceted care plan in place
- Asking patients about any previous fall episodes on every admission
- Ensuring patients have appropriate footwear
- Ensuring call bell visible and within reach
Medicines management teams, as well as providing direct input into falls prevention groups, and supporting staff training and development, can impact on reducing harm from falls by supporting the implementation of the following specific recommendation from the guide:
- Avoiding unnecessary hypnotic and sedative medication
Updated data published by the NPSA show that a total 283,438 slips, trips and falls (acute care 208,338; mental health 36,482; and primary care organisations 38,618) were reported to the NPSA between October 1st 2008 and September 30th 2009.2 A patient falling is the most common inpatient safety incident reported to the NPSA and the immediate annual healthcare cost of treating falls is over £15million for England and Wales.3
What does this mean to medicines management?
Elderly people are often a frail and vulnerable population at great risk of falls. Medicines management teams can focus on the identification and implementation of prevention strategies that may help to support patients and minimise risks; strategies such as medication review, benzodiazepine withdrawal clinics, and targeted prescribing advice. PCTs may also consider targeting community pharmacy medicines use reviews (MURs) to patients who are taking medicines associated with a risk of falls.
The National Institute for Health and Clinical Excellence (NICE) principles of practice as outlined in the guide Clinical practice guideline for the assessment and prevention of falls in older people4 recommends involving patients and/or their carers in the shared decision-making process of individualised falls prevention strategies, in particular, the knowledge of those patients who are at long-term risk of falling and have been self-managing this risk. The guide also recommends that an integrated approach to falls prevention with a clear strategy and policy should be implemented across all healthcare organisations.
Healthcare professionals should look to underpin patient safety procedures for elderly patients within an inpatient setting, but additionally work together with healthcare professionals in the community to develop integrated falls services, as emphasised in the National Service Framework for Older People in England.5
How does this relate to other publications or evidence?
In 1999, Leipzig et al6 found that an increasing number of medicines are associated with falls and suggested that sedatives such as benodiazepines and drugs causing hypotension should be considered as potential causes.
This was highlighted more recently in the January 2010 NPC MeReC rapid review7 following a systematic meta-analysis of English based articles from 1996-2007 by Woolcott et al (2009)8, which raised concern that an increased risk of falls in people older than 60 years is associated with taking benzodiazepines, other sedatives and hypnotics, and antidepressants. The review also suggests that antihypertensives and non-steroidal anti-inflammatory drugs (NSAIDs) may be associated with a smaller, but still significant increased risk of falling.A study by Zermansky et al (2006)9 found that a medication review of care home residents by pharmacists reduced falls significantly. Including face-to-face medication reviews that involve patients in the decision-making process as part of an overall falls assessment would be just one strategy to support a reduction in falls.
The NPC publication A Guide to Medication Review, 200810 is a useful resource for those providing medication reviews in a wide range of care settings – with the needs of vulnerable groups, such as the elderly particularly in mind. A supporting NPC section is also available.
1. National Patient Safety Agency and Patient Safety First campaign (2009). The ‘How to’ Guide for Reducing Harm from Falls.
2. National Patient Safety Agency (2010). Slips, trips and falls data update – from acute and community hospitals and mental health units in England and Wales.
3. National Patient Safety Agency (2007). The third report from the Patient Safety Observatory: Slips, trips and falls in hospital report.
4. National Institute for Health and Clinical Excellence (2004). Clinical practice guideline for the assessment and prevention of falls in older people.
5. Department of Health (2001). The National Service Framework for Older People.
6. Leipzig, R. M., Cumming R. G., and Tinetti, M. E. Drugs and falls in older people: a systematic review and meta-analysis — psychotropic drugs. Journal of the American Geriatric Society 1999; 47: 30-9.
8. Woolcott, J. C., Richardson, K. J., Wiens, M. O., Patel, B., Marin, J., Khan, K. M., and Marra C. A. (2009). Meta-analysis of the impact of 9 medication classes on falls in elderly persons.
9. Zermansky, A.G., Alldred, D. P., Petty, D. R., Raynor, D. K., Freemantle, N., Eastaugh, J., and Bowie, P. Clinical medication review by a pharmacist of elderly people living in care homes – randomised controlled trial. Age and Ageing (2006): 35: 586-91.
10. NPC, NPC plus and Medicines Partnership Programme (2008). A Guide to Medication Review 2008.