A successful approach to fall prevention in an outpatient hemodialysis center.

BACKGROUND AND OBJECTIVES Hemodialysis patients are at high risk both for falling and for serious complications associated with falls, but few fall studies have specifically focused on this population. Falls occurring in an outpatient dialysis unit were reviewed to identify contributing factors and implement interventions designed to reduce fall risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A root cause analysis of all fall incidents occurring at an outpatient hemodialysis center during a 4-year period was conducted. A targeted intervention program to reduce falls was then implemented. Risk of falls in the postintervention period was compared with that of the baseline period. RESULTS In the baseline period, a total of 22 falls occurred involving 14 patients and 8 staff members or visitors (incidence of 50 falls per 100,000 dialysis treatments). Root cause analyses identified staff educational deficits and environmental hazards as the most significant risk factors for fall incidents. After an interventional period that focused on formal staff education and environmental modifications, a total of only 3 additional falls (2 patients and 1 staff member) during 21 months of follow-up (14 falls per 100,000 dialysis treatments, P = 0.01) were observed. CONCLUSIONS Several modifiable risk factors for falls occurring in the high-risk setting of an outpatient hemodialysis unit were identified as a result of this formal analysis of fall incidents. Through a targeted series of interventions, a marked reduction in fall risk was achieved.