An imperfect world calls for an increase in risk management

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Panel: Saving Medicare requires public support
Panel: Saving Medicare requires public support
In a perfect world, the risk of resident falls and medication errors wouldn't be an issue for nursing home operators.

Unfortunately, the world is far from perfect. Falls and drug errors remain top concerns for long-term care providers, who have to come up with effective ways to prevent, or at least deter, them.
Not to do so adequately has become a form of economic suicide. The numbers, quite frankly, can be intimidating.

UCLA Professor of Medicine Laurence Rubenstein, MD, has spent decades collecting injury data and his research team's reports are renowned in academic and clinical circles. 

Following are a few statistics from his compelling list of nursing home-specific accident figures over the years:

• Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many more falls go unreported.

• As many as 3 out of 4 people in nursing homes fall each year – twice the rate of falls for seniors living independently.

• The average is 2.6 falls per person per year.

• Nursing homes account for about 20% of deaths from falls in the 65-and-older age group. 

• About 1,800 people living in U.S. nursing homes die each year from falls; 10% to 20% of nursing home falls cause serious injuries and 2% to 6% cause fractures.

Yet while those numbers are enough to give administrators cause for concern, there is also reason for optimism on the risk management front, says Chip Kessler, general manager of Johnson City, TN-based Extended Care Products.

“Falls, medication errors and resident wandering obviously do occur, though it is my belief that our nation's nursing facilities for the most part are doing a very good job of staying on top of these areas,” he said.

“This is evidenced by such things as increased emphasis on enacting fall prevention programs.”
Despite data that suggest falls are common in long-term care facilities, Kessler maintains that the numbers must be kept in perspective.

“Falls and resident wandering, while taking place, are not always the fault of the facility – rather, they are the result of the limitations our nursing facility caregivers face,” he said.

“It is often a fact that a resident who has a history of falling at home may still fall in the nursing home. Why? It can be traced back to personal history and despite a facility's reasonable effort to prevent it, a fall may still take place.”

Brian Verban, director of sales for Milwaukee-based HomeFree Systems, agrees that “it is nearly impossible” to prevent every fall from happening, but he maintains that new technology can help reduce the number of incidents.

“Systems now offer reporting tools that allow providers to develop a proactive approach centered around the care plan to help manage the falls,” Verban said. “When evaluating a fall management system, look for one that is able to alert staff via phones or pagers with the resident name and location. When a fall does occur, it's crucial that the staff be able to respond immediately.”

Assessing risk factors

The key to preventing resident falls is in assessing each individual's circumstances, risk management specialists say. And the most appropriate time and place to do that is when the resident enters the facility, says Doug Nern, distribution sales manager for Lincoln, NE-based Stanley-Senior Technologies.

“Assessing residents' likelihood to fall must not only be accomplished at the time of admission, but must be ongoing with changes in the resident's state of health, change in medications or other determining factors that are dynamic in nature,” he notes. “The overall assessment of residents must include the sociological, physiological and environmental factors that comprise the risk. This process should be carried out not just by a risk management department, but by the staff that work with residents on an everyday basis.”

Covington, KY-based Omnicare has launched an enhanced falls/fracture risk management program, which, as W. Gary Erwin explains, uses clinical and biographical data to identify which residents have the greatest risk of falling.

“To ensure the appropriate assessment and documentation required for the program, we request that our client facilities provide us with information from their quality indicator report so that we can identify residents with incidence of new fractures or prevalence of falls,” said Erwin, senior vice president of professional services and president of Omnicare Senior Health Outcomes. “During a monthly medication regimen review performed by our consultant pharmacist, we use information available in the individual residents' Minimum Data Set, documentation found in the medical record and discussions with the interdisciplinary team as they evaluate and document the possibility of medications contributing to falls. In addition, we offer education to the facility staff on recognizing the environmental as well as the medical interventions that might reduce the likelihood of falling.”

Medication station

Medication errors are at least as consequential as resident falls in the risk management arena, as statistics from various organizations reveal:

• The Academy of Managed Care Pharmacy reports that medication errors occur in approximately one in every five doses administered in hospitals.

• The U.S. Food and Drug Administration states that there is at least one death per day and that 1.3 million people are injured each year due to medication errors.

• The Journal of the American Pharmacists Association estimates that the annual cost of drug-related morbidity and mortality is nearly $177 billion in the United States.

The National Coordinating Council for Medication Errors defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer.” Common causes of medication errors include incorrect diagnosis, prescribing errors, negative drug interactions, dose miscalculations, incorrect drug administration and lack of patient education. Other factors that can contribute are job-related stress, improper training or education and sound-alike/look-alike packaging of medications.

Erwin points out that the medication errors most often linked to litigation involve the facility staff's failure to properly monitor and administer medication.

“These include medications administered with the incorrect dose as well as medications documented as administered but not given and the adverse consequences of these actions,” he said.

“Medications of particular concern include those with black box warnings, those with a narrow therapeutic window, those that result in greater risk than benefit, cognitive decline and weight loss, as well as those with dangerous drug interactions.”

As part of the facility's interdisciplinary team, an Omnicare consultant pharmacist provides in-services, training and educational support to ensure staff understands proper medication monitoring and administration to enhance compliance and mitigate risk, Erwin said.

Nern adds that medication errors don't only arise in the form of improper dosing of the medication, but also when multiple drugs are prescribed without fully investigating the possible contraindications that might result.

“Even if contraindications are not given for certain multiple drug use, the resident must be closely monitored to see if side effects such as dizziness or confusion might occur resulting in the possible falls or wandering that long-term care facilities are trying so hard to prevent,” he said.
Expectations management

Taking a holistic approach is perhaps the most logical and effective risk management strategy, said Kessler, who favors a concept called “expectations management,” which has been evolving in the long-term care industry for several years.

“Expectations management is true risk management in the sense that facilities and families work together to make sure that the resident receives the best care that's reasonably possible,” Kessler said.

“It begins with the family being educated about the realities of care so that they understand what the facility is capable of doing for their loved one. The next step is the family trusting and respecting what facility staff can offer the resident in the way of care and in turn understanding what the facility's limitations are. Third is the family agreeing to be a partner in the resident's care.”

The concept is readily accepted by virtually all long-term care interests, including providers, risk management firms, insurance companies, healthcare associations and long-term care attorneys, Kessler said.

“It is the most innovative risk management strategy in existence today,” he said.