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The "avoidable patient fall" present a very common case of falls in the eldership in the in-patient setting. An 88-year-old gentleman with COPD, aortic valve replacement, ls/p laminectomy, and BPH brought into the ER by his wife and daughter for increasing worsening confusion, hallucinations, disturbed sleep, poor appetite and increased shortness of breath.

The events that I notice that built on each other starting with the patient came with confusion with multiple comorbidities. After the possible diagnosis of sepsis was made, there was inadequate protocol of falls initiated for the patients. Furthermore, after family member informed off the staffs of the risk of falling but no specific action was taken. I feel that the hand over was also inadequate and put him in a bay at the end of the ward where it was hard to monitor was not acceptable. Consequently, at 21:45, patient found on the floor having falling described that patient was very confused. A diagnosed of the fracture was delay. Moreover, the ED uses a computer system but the ward use paper forms, there is a disconnect in the documentation and recording.

A better decision could have been made right at the time to admission with chief complaint that he has been brought in for worsening confusion. It should be noted that elderly patients would find a strange environment would be a distressing and increase the risk of wandering and falling. Better protocol for the management of patients who are at risk for falling should have been implemented immediately and he should have not been placed at the end of the ward.

The complexity of the medical system where there was a busy medical ward, patient presenting with acute fall on top of the worsening chronic medical system which made it cloudy for the trainee doctor. There was no mention of attending physicians to give the guidance and supervision for the inexperienced residents. Not every hole exists in the system will lead to a mistake but the compounded factors will definitely lead to an avoidable event as illustrated in this case. rovide feedback for this