Journal of Gerontological Nursing

Interventions for Safety

Margaret J Kustaborder, RN, MN; Marilyn Rigney, RN


Promoting functional restoration/maintenance may be more beneficial to the elderly patient than applying restraints to prevent risk of injury.


Promoting functional restoration/maintenance may be more beneficial to the elderly patient than applying restraints to prevent risk of injury.

Accidents in health care institutions that involve elderly patients occur with unfortunate regularity, even when wellpublished environmental safety standards and procedures are in use.

Rodstein determined that the aging process, with accompanying decrements in response time, muscle weakness, vision, and hearing, as well as the use of multiple medications, was the greatest cause of accidents in the hospital and the community.1 Acute disease resulting in confusion, acute changes in cardiac status, and transient cerebral ischemia compounded the frequency and severity of accidents.2

Stone believed there was no way to eliminate hospital accidents, particularly in those institutions where care for the elderly is provided. He postulated there was a reasonable standard rate for accidents.3 Based on research and experience, it was accepted that some elderly patients would have accidents. However, no data had been collected to determine if the number of accidents occurring at our facililty was reasonable, or if some accidents could be prevented.

This study was implemented in two parts. Phase I gathered data on the number and variety of accidents. This information was evaluated and used as the basis for Phase II, an attempt to decrease the accident rate by using appropriate nursing interventions.


Setting and Sample

St. John's Hospital North is a subacute, 98-bed section of St. John's Hospital, an850-bed general hospital located in the center of Illinois. St. John's North was designed to provide a continuum of care for those patients, particularly the elderly, who need more time for recuperation and rehabilitation, or a place for terminally ill patients to die in comfort and with dignity. The average age of the patients admitted to St. John's North during 1979 was 73 years, with a range of 18 to 98 years. During 1980, the average age was 74 years, with a range of 18 to 99 years. The two nursing units from which data were gathered included a 56-bed skilled care unit and a 34-bed skilled care unit.

The definition of an accident accepted for this study is any sudden or unexpected event that may lead to the injury of a patient.4 An incident at St. John's Hospital is defined as any happening that is not consistent with the routine operation of the hospital or routine care of a particular patient. Therefore, any patient aged 55 years or older who had an accident at St. John's North, and for whom an incident report form was completed, was considered a participant in this study.

Summary of Phase I

Data to identify the number of accidents, location, time of occurrence, and the circumstances relative to each accident were collected in Phase I. The information gathered from October 1979 through February 1980 indicated that the majority of patient accidents occurred in patient rooms and adjoining bathrooms.

After examining the results of Phase I, the only consistent thread relating accidents to an apparent cause over which nursing had control was the increased number of accidents occurring at the time of nursing shift change and report, and staff coffee breaks and meals (see Figure 1). This led to the assumption that many accidents occurred because there was not enough staff on the nursing units at specific times of the day to answer patient requests for assistance. Therefore, Phase II of this study was devised to determine if specific nursing interventions would decrease the number of accidents involving middle-aged and elderly patients.

Because there were differing opinions in the literature regarding the importance of the time of year and its influence on the number of patient accidents, it was decided, for consistency, to have Phase II take place October 1980 through February 1981.

Procedure Phase II

The authors, supervisors and nursing staff met to identify problems and interventions that might decrease the number of patient accidents.

There were many problems and interventions considered, some of which involved cooperation from physicians and other members of the health team. It was believed that having others involved might complicate and/ or delay efforts to reduce accidents and to complete the study. Therefore, interventions that could be implemented by the nursing staff alone were selected.

Problems identified were: (1) that too many staff members were off the nursing unit at certain times of the day; (2) that signal cords were not always within reach of the patient; (3) that signal lights were not always answered immediately; and, (4) that bathroom accidents appeared to occur because patients with special health problems (amputation, confusion, etc.) were left unattended.

Using these identified problems, the following nursing interventions were developed:

1. Staff were divided into three groups for coffee breaks and meals so that only one-third of the nursing staff was off the unit at any one time.

2. Signal controls on very long cords were obtained for each patient room so that any patient who was out of bed had a method of calling for assistance.

3. Nursing assistants were to be assigned in pairs as "Buddies" to each other. Each of the nursing assistants would have his/her own assigned patients but, when one nursing assistant needed to leave the nursing unit, he/she would "report off" to the assigned Buddy and the team leader. The Buddy then would be responsible for answering patient requests for assistance until the assigned nursing assistant returned to the unit.

4. Nursing staff were directed to remain in the same room with patients using a bedside commode or the bathroom facilities if the patient was brain damaged, confused, sedated, receiving continuous oxygen, or had an amputated lower extremity.

The nursing supervisors presented the interventions and method of data gathering to nursing staff on all three shifts. The hospital incident report forms were used for information regarding age, sex, date and time of accident, medical diagnosis, description of how and where the accident occurred, injuries sustained, and notification of the attending physician.

In addition, the following information was recorded: (1) patient census during that shift, (2) number and titles of nursing staff on duty, (3) location of assigned nursing assistant and Buddy at the time of the accident, (4) location of the signal cord in relation to the patient, (5) if the signal light was on, and (6) the mental status of the patient determined by the patient's ability to follow directions and respond appropriately when asked name, place, and time.


There were 85 accidents involving 60 patients. The mean age of the patients was 83 years. Twenty-five patients were men and 35 patients were women. Forty-one patients (68%) suffered no injuries as a result of their accidents. The injuries of the remaining 19 patients (32%) were minor, consisting of small abrasions, minor lacerations, contusions, and pain.

Table 1 compares the age, number of accidents, census, admissions, and caregivers on duty in Phase I and Phase II. Patient health problems were multiple, as expected. However, for the purposes of this study, the admission diagnosis is used for the comparison of health problems in Phase I and Phase II (see Table 2).

As reported by others, this research project also showed that most accidents happen between 6 AM and 6 PM.5'6 There were 61 accidents during the daytime hours and 19 accidents from 6 PM to 6 am. See the Figure for the relationship of accidents to time of day compared with data gathered in Phase I.

The location of patient accidents was similar in both Phase I and Phase II. Most accidents occurred in patient rooms and adjoining bathrooms. In 68 of the accidents in Phase II, the assigned nursing assistant was on the nursing unit. During two of the accidents, the nursing assistant was off the unit, but the Buddy was present. In two other accidents, both the nursing assistant and Buddy were off the unit. The location of the assigned nursing assistant was not recorded for 13 accidents and the location of the Buddy was not recorded for 29 accidents.

The signal cord was within patient reach for 53 accidents, but was turned on for only 11 accidents. The signal cord was not within reach for 15 accidents and its location was not recorded for 17 accidents.

Fifteen accidents took place in the patient bathrooms. A nursing assistant was present with four of the patients when the accidents occurred. Of the 15 patients, only those four were listed as needing someone in attendance because of their problems.

In 50 accidents, the patients were alert and oriented to time, person, and place. Twenty-six accidents involved disoriented patients. The patient's orientation was not recorded for nine accidents.


At the conclusion of Phase I of this study, the authors and nursing supervisors believed that accidents could be decreased with the use of appropriate nursing interventions. This did not happen. There was a 9.4% increase in census on accident days in Phase II and, interestingly, a 9.0% increase in accidents. The registered nurse was responsible for an average of three more patients in Phase II, but there were slightly less patients per licensed practical nurse and nursing assistant.

Scheduling staff relief time so that no more than one-third of the staff were off the unit at any given time changed the time distribution of accidents to a more random pattern (Figure) but did not decrease the total number of accidents occurring between 6 AM and 6 PM.

Parrish and Weil found that older patients who had neurologic, cardiovascular, oncologic, orthopedic, and genitourinary problems had more accidents than younger patients in an acute care hospital. Rodstein associated chronic disease, acute changes in cardiac status, and the aging process with increased accidents, especially in patients of advanced age.1'2 The admission diagnoses (Table 2) show that the majority of St. John's North patients who had accidents suffered from these same health problems.









The accidents were as individual as the patients involved. However, 54 of the 85 accidents can be categorized generally as follows:

1. Nine patients climbed over bed rails or the foot of the bed.

2. Six patients had accidents associated with wheelchairs; for example, standing up, sitting down, or leaning forward causing the chair to tip over.

3. Twelve patients fell while getting into or out of bed, even though the bed wheels were locked and the bed was in the low position.

4. Fifteen patients fell when getting on or off the toilet or bedside commode.

5. Six patients had falls while sitting down on or getting up from an easy chair.

6. Six patients fell while walking to the bathroom or to the bed.

Of these 54 accidents, 39 involved patients oriented to time, person and place, and 15 accidents involved disoriented patients. The other 31 accidents are too varied to list.

Compliance of the nursing staff was good when implementing the nursing interventions but deficient when collecting data, as evidenced by the number of facts not recorded. The incident report forms were completed, but the additional information requested was not always gathered. The reason for not recording this information is unknown.




The data collected in Phase II, however, were significant. The nursing units Were well covered with nursing assistants when accidents occurred. The signal cord was within reach of at least 62% of patients who had accidents, but was used by only 1 3% of them. In 59% of the accidents, the patients were alert and oriented, as demonstrated by their ability to follow directions and respond appropriately. It appears that some elderly patients choose to maintain as much independence as possible in a health care facility and do not ask for assistance. This attitude of independence is encouraged at St. John's North. Our philosophy of care focuses on restoration and /or maintenance of function in the activities of daily living so the elderly patient may return to his/her place in the community. With this philosophy, it is difficult to encourage dependence while the patient is in our facility, even if this might reduce accidents.

The nature of St. John's North is unique - patients who have been in acule care hospitals from three days to many weeks are transferred to this facility, where they remain for another two to three weeks. These patients are exposed to the hospital environment for a great length of time. Parrish indicates that length of exposure is an important factor leading to accident-prone situations.4 The transfer of elderly patients from a familiar situation to one in which they do not know the staff, the routine, or what is expected of them, could be an additional factor contributing to accidents.

In a resident home for the aged, Rodstein reported 147 accidents for 376 residents, a 39% accident rate. ' In an acute care hospital, Fagin and Vita reported 62 accidents for 1000 admissions (6.2%) with patients aged 71 to 80 years.5 During Phase I of this project, 22% of the patients admitted had accidents, and 24% of the patients admitted in Phase II had accidents. The rate of accidents is not as high as in long-term care and not as low as in acute care, which is consistent with our designation as a subacute facility. No useful comparative accident data could be found in the literature to determine a normal standard rate for accidents in a subacute facility similar to St. John's North.

Consistent awareness of safety measures is necessary in the prevention of accidents in all types of health care institutions and it is imperative that all health care providers work to decrease accidents. Miller showed that rehabilitation to maintain or restore function, which is dictated by good medical practice, has the builtin risk of patient injuries.6 This risk must be accepted by "patient, family physician, staff, and society."

It must be understood that promoting functional restoration/ maintenance is more beneficial to the quality of life of the elderly patient than taking away the patient's freedom of choice with restraint measures that might (but not always) prevent the risk of injury.


  • 1. Rodstein M: Accidents among the aged: Incidence, causes and prevention. J Chronic Dis 1964; 17:515-526.
  • 2. Rodstein M, Camus A: Interrelation of heart disease and accidents. Geriatrics 1973; 28:87-96.
  • 3. Stone EP: What is a reasonable standard rate for patient accidents. Hospitals 1962; 36:43-46.
  • 4. Parrish H, Weil T: Patient accidents occurring in hospitals: Epidemiologic study of 614 accidents. NY State J Med 1958; 58:838-846.
  • 5. Fagin D, Vita M Sr: Who? Where? When? How? : An analysis of 868 inpatient accidents. Hospitals 1965; 39: 60-65.
  • 6. Elliott D: Accidents in nursing homes: Implications for patients and administrators, in Miller M: Current Issues in Clinical Geriatrics. New York, The Tiresias Press, 1979, pp 97-137.
  • Bibliography
  • Lynn F: Incidents- Need they be accidents? Am J Nurs 1980; 80: 1098-1 101.
  • Naylor MD, Rosin AJ: Falling as a cause of admission to a geriatric unit. Practitioner 1970; 205:327-330.
  • Rodstein M: Accidents among the aged, in Reichel W (ed): Clinical Aspects of Aging. Baltimore, MD. Williams and Wilkins. 1978, pp 499-513.






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