Citation

Kim I, Won S, Lee M, Lee W. Med. Sci. Law 2018; 58(1): 16-24.

Affiliation

Department of Medical Law and Ethics, College of Medicine, Yonsei University, Asian Institute for Bioethics and Health Law, Korea.

Copyright

(Copyright © 2018, British Academy of Forensic Sciences, Publisher SAGE Publishing)

DOI

10.1177/0025802417735265

PMID

29065775

Abstract

The aim of this study was to find out the risk factors through analysis of seven medical malpractice judgments related to fall injuries. The risk factors were analysed by using the framework that approaches falls from a systems perspective and comprised people, organisational or environmental factors, with each factor being comprised of subfactors. The risk factors found in each of the seven judgments were aggregated into one framework. The risk factors related to patients (i.e. the people factor) were age, pain, related disease, activities and functional status, urination state, cognitive function impairment, past history of fall, blood transfusion, sleep endoscopy state and uncooperative attitude. The risk factors related to the medical staff and caregivers (i.e. people factor) were observation negligence, no fall prevention activities and negligence in managing high-risk group for fall. Organisational risk factors were a lack of workforce, a lack of training, neglecting the management of the high-risk group, neglecting the management of caregivers and the absence of a fall prevention procedure. Regarding the environment, the risk factors were found to be the emergency room, chairs without a backrest and the examination table. Identifying risk factors is essential for preventing fall accidents, since falls are preventable patient-safety incidents. Falls do not happen as a result of a single risk factor. Therefore, a systems approach is effective to identify risk factors, especially organisational and environmental factors.

Language: en

Keywords

Falls; malpractice; patient safety