Falls in the Operating Room

Educational Objectives

The goal of this program is to reduce patient falls in the operating room (OR). After hearing and assimilating this program, the clinician will be better able to:

1. Identify ways to prevent patient falls in the operating room.

Summary

Introduction: patients in the operating room (OR) require vigilance, especially during induction and emergence from anesthesia as the risk for fall is greater during these times; falls of patients in the operating room may have unfavorable outcomes as they are under anesthesia or certain medications most of the time and are unable to brace themselves for impact; patients under anesthesia typically lead with their head when they fall, resulting in head injury; the clinician should be familiar with OR equipment, especially the OR table, eg, weight limits and related characteristics

Factors contributing to falls: obesity is a major risk factor for falls, especially when changing the position of the patient; vigilance is required while turning the patient prone or lateral; inactions and distractions during these times can contribute to risk; trainees often are not aware of these risks, thereby putting patients at risk; the nurse may remove the safety strap and leave the room to retrieve the stretcher (should be informed about the risk for fall); extreme positions also increase risk for fall, especially steep Trendelenburg position; failure to lock the wheels while transferring patients from the OR table to the stretcher is dangerous; medical staff should ensure that wheel lock mechanisms function properly

Claims related to falls: Prielipp et al (2017) — identified 21 closed claims in which patients fell from the OR table; several patients were in a pain clinic or receiving nerve blocks for chronic pain; 10 claims resulted in payments of $18,000 to $1,000,000 to the plaintiff; liability for anesthesiologists is significant

Root cause analysis: Veterans Affairs, during root cause analysis, identified risk factors for fall, ie, tilting of the OR table, absence of safety restraints, patient’s movement during emergence, and OR bed malfunction; Mayo Clinic reported that, with steep Trendelenburg position, falls occur very quickly, and patients hit the floor hard in the absence of attention; once the fall is initiated, it is difficult to stop; a good strategy is to get under the patient to provide a cushion while they are sliding from the bed; consider using a foam pad on the table for enhanced grip; clinicians should not be complacent as patients are always at risk

Strategies to prevent fall: use strong belts to hold the patient; Velcro straps may not be strong enough to secure obese patients; the OR table acts as a fulcrum; the table may become unstable if positioned too far above or below the base; locking the table causes a piston to descend and lift the wheels off the floor; the surface area in contact with the floor is reduced every time the table is unlocked, which can lead to the table tilting with an obese patient; weight limits of the OR table are usually indicated in completely neutral (level) position; however, unlocking the table or articulating far away from the base may increase risk; manufacturer’s instruction suggests avoiding unlocking the table when the patient is on the bed; lowering the leg portion of the table with a sturdy piece of equipment under it results in raising the pedestal and base; pay attention to small details; workflow interruptions or disruption of the normal routine of securing the patient can create dangerous situations; inside the pedestal of the OR table is equipment that can break and fracture; 2 bolts are usually required for the tilt cylinder bracket; in some cases, one bolt is already broken and, when overweight patients are placed on the bed, the second bolt may also break; excessive play in the bed should raise concern about a potential problem

Readings

Griffin JD, Donovan A, Hollister N. Caught in the slips. BMJ Case Rep. 2010;2010:bcr08.2009.2186. Published 2010 May 13. doi:10.1136/bcr.08.2009.2186; Prielipp RC, Weinkauf JL, Esser TM, et al. Falls from the O.R. or procedure table. Anesth Analg. 2017;125(3):846-851. doi:10.1213/ANE.0000000000002125; Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the operating room setting: An analysis of reported safety events. J Healthc Risk Manag. 2022;42(1):9-14. doi:10.1002/jhrm.21503.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. McAllister was recorded at Texas Society of Anesthesiologists 2023 Annual Meeting, held September 7-10, 2023, in Round Rock, TX, and presented by the Texas Society of Anesthesiologists. For information on future CME activities from this presenter, please visit www.tsa.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

AN660203

Qualifies for:

ABA MOCA, Risk Mgmt/Patient Safety/Medical Errors

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.