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PSNet: Patient Safety Network
Journal Article
Study

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17(1):30-35.

Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.