Risk assessment of patient falls while taking medications ordered in a teaching hospital

Objective: to stratify prescribed medication in a fall risk scale, identifying subgroups of drugs and inpatient units with higher risk of falls. Method: retrospective study on prescription order forms given by medical clinic, surgical clinic, and general intensive care unit. Risk factors under consideration: 1) orthostatic hypotension; 2) arterial hypotension; 3) arterial hypertension; 4) bradycardia; 5) psychomotor agitation; 6) mental confusion; 7) dizziness; 8) drowsiness/sedation; 9) reduced eyesight; 10) seizures; 11) atonia/dystonia/muscle weakness; 12) hypoglycemia; 13) urgent urination and 14) urgent defecation/diarrhea. Risk levels adopted: 0: 0 factor; I: 1-2 factors; II: 3-5 factors; III: 6-9 factors; IV: 10-14 factors. Results: 3893 drugs were analyzed and stratifi ed in levels: 0 22.7%; I 33.5%; II 28%; III 15.1%; IV 0.7%. Levels III and IV more often refer to drugs for stomach acid disorders, 22.6%, and psycholeptics, 100%. Conclusion: knowing the risk factors associated with medication may help prevent and reduce falls, especially when therapeutic regimens cannot be modifi ed.


INTRODUCTION
A fall is an unintentional displacement of the body to a level that is lower than the initial position without having the ability to timely correct it.It is determined by multifactor circumstances that compromise stability (1) .
Patient falls are the most frequent adverse events in hospitals, with consequences such as the compromise of physical and mental well-being of patients and increased inpatient time and economic and social costs (2)(3) .With this concern in mind, national (4)(5)(6)(7) and international (2,8) accreditation and regulatory bodies recommend that health care services establish strategies and actions for fall prevention.
Most falls have multifactor etiology.These events may come as a result of several risk factors that must be known in order to reduce its probability of occurrence (9)(10)(11) .
Risk factors for falls can be categorized as intrinsic, which are those directly associated with the individual, or extrinsic, which are those related to environmental factors.Intrinsic factors include age, sex, certain drug effects, and clinical conditions, such as heart disease, osteoarticular disorder, neurologic and mental state, gait disorders, sedentary lifestyle, and nutritional deficiency.Extrinsic factors include poor lighting, obstacles, irregular or slippery floor, protection bars without elevation, and the lack of banisters (3,(9)(10)(11)(12)(13)(14)(15) .
Most inpatient adult falls, 85-90%, are related to intrinsic factors (9) .This information is very important, because extrinsic factors may be changed, or even eliminated, but intrinsic factors many times cannot be modified.
The purpose of this study was to verify the frequency of drugs ordered in medical clinic, surgical clinic, and general intensive care unit, stratified in a scale of risk for patient falls.

METHOD
A retrospective study was conducted on prescription order forms of inpatients of a teaching hospital at the countryside the state of Paraná, Brazil, which were sent to the Hospital Pharmacy Service between June 1st and 15th of 2013, totaling 309 prescription orders.
Data collection included a structured form, divided into two parts: 1) inpatient units and 2) risk levels for falls of patients under ordered drugs.

Inclusion Criteria
All standard drugs of the institution that were ordered for adult male and female inpatients who were at the medical clinic, surgical clinic and general intensive care unit (ICU) during the data collection period were analyzed.
Standard drugs in use were considered, as approved by the Institutional Therapeutics and Pharmacy Commission.

Exclusion Criteria
Medical prescription orders of inpatients of units that were not included in the study and non-standard ordered medications were excluded.

Drug Classification
Drug assessment was based on the Anatomical Therapeutic Chemical (ATC) Classification System of the WHO Collaborating Centre for Drug Statistics Methodology -World Health Organization -Drug Utilization Research Group (WHO-DURG).ATC divides and codes drugs into 14 main anatomical groups (1st level of classification), according to the body or system on which they act.The drugs in each anatomical group are arranged in therapeutic subgroups (2nd level) and sequentially in pharmacological (3rd level) and chemical (4th level) subgroups, and the 5th level is the drug itself.Based on the ATC, the drug N05BA01, for example, corresponds to: N nervous system, 05 psycholeptics, B anxiolytics, A benzodiazepine derivatives and 01 diazepam.
This investigation adopted the 2nd level of classification: therapeutic subgroups.

Risk Factors
The determination of risk factors for patient falls was done by reviewing the relevant literature.

Verification of the effects of the drugs classified as risk factors for patient falls
The internet-based Micromedex ® 2.0 Truven Health Analytics Inc database was used to verify the effects of drugs classified as risk factors for patient falls upon review.Only the effects in recommended dosage and described as the most common or that took place 5% of the time or more were considered.Effects described as rare, very rare, occasional, isolated or not proven were excluded.

Data Analysis
Data were typed, revised, processed and analyzed using the program Microsoft ® Office Excel 2010, and submitted to descriptive analysis.
This study was approved by the Research Ethics Committee of the State University of Ponta Grossa, as per Opinion No. 347625/2013.

RESULTS
This study analyzed 309 prescription orders; of these, 138 (44.7%) came from the medical clinic, 77 (24.9%) came from the surgical clinic, and 94 (30.4%) came from the general intensive care unit of a teaching hospital.

DISCUSSION
The highest number of ordered drugs took place in the medical clinic (46.2%) and in the ICU (43.4%).The use of drugs is an intrinsic factor strongly related to patient falls (13,15) , and the risk of falls increases with the number of ordered drugs.Ziere et al (2006) (17) analyzed falls in a population aged 55 years or older and found a higher percentage of falls, 60% versus 25% respectively, in individuals who received six or more drugs than those who received only one.In another study (11) 81 drugs with risk associated with patient falls were analyzed.During the period of study, 151 patients fell, and out of these, 144 (95.4%) were taking at least 1 drug classified by the authors as a high-risk medication.
The frequency of ordered medications stratified as Level II (3-5 factors) at the surgical clinic (17.5%) was lower when compared to the medical clinic (29.0%) and to the ICU (29.5%).However, the ordered drugs stratified as Level III (6-9 factors), therefore with higher risk, were more often ordered (26.1%) at the surgical clinic, in comparison with the ones ordered at the medical clinic (12.9%) and the UCI (14.8%).
Regarding the ordered medication stratified as Level III, we noted that the therapeutic groups most often observed were A02 Drugs for stomach acid disorders (22.6%) and A03 Drugs for functional gastrointestinal disorders (22.4%).However, they were not mentioned in the studied literature, although drugs in these subgroups, such as ranitidine and metoclopramide, show many of the risk factors included in this study.
Several studies have shown that drugs acting on the central nervous system have higher risk for patient fall, especially benzodiazepine and antipsychotics (10)(11)(12)15,17) . In thi investigation, 19.7% of the psycholeptics showed6-9 risk factors for  falls (Level III).Psycholeptics alter cognitive function such as attention, memory and orientation, which are important for postural control and balance.In addition, they cause sedation, psychomotor changes, muscle relaxation and adrenergic blockade, which increase orthostatic hypotension (13) , regarded by many authors as a great risk factor for falls (2,6,12,(17)(18) .In this study, only 0.7% of the ordered drugs were stratified as having a higher risk for falls, Level IV (10-14 factors); however, 100%belonged to the therapeutic subgroup N05 Psycholeptics.As for the inpatient units, only 1.4% and 0.2% of the total medication ordered at the medical clinic and the ICU, respectively, were stratified as Level IV.This is important information because inpatients under intensive care, despite having more severe clinical conditions, are assisted full time, and in most cases they are sedated, and so they have a lower risk of falling.Inpatients of medical clinic units may feel self-sufficient to perform basic activities, such as walking around and going to the toilet, and therefore they are more exposed to extrinsic risk factors.
It was also noted that 18.6% of the ordered medications stratified as Level III belonged to the subgroup A10 Drugs used for diabetes.The main effect of this therapeutic subgroup that may cause falls is hypoglycemia.In the work of Johnston et al. (19) , patients with episodes of hypoglycemia had 70% higher probability of having fall-related fractures than patients without hypoglycemia.
Some authors point toC03 Diuretics as high-risk drugs for falls (3,11,17) .In this research, diuretics were stratified as Level II (3-4 factors) and accounted for 16.2% of the ordered medications in this category.Diuresis is associated with arterial hypotension, atonia, dystonia or muscle weakness, urgent urination and, like many N05 Psycholeptics, with orthostatic hypotension.
It is important to stress that falls are a multifactor care risk that may occur due to previous patient conditions, that is, conditions that were present at the time of admission to the hospital, as well as when care was provided during the stay.During the development of this study, the authors did not consider causal or interfering factors such as age, clinical condition, pathologies, and especially medication currently in use or previously used by the patient.The focus of this study was to contribute to the knowledge about the medication used in the hospital so that specific safety prevention measures could be implemented in order to preserve the health of patients and quality of care.

CONCLUSION
Although this research had a descriptive nature whose purpose was not to infer cause and effect among the several risk factors for falls, it was possible to find results that were similar to the ones found in the scientific literature on the subject.
The knowledge of risk factors associated with medications can contribute to the prevention and reduction of falls, especially when therapeutic regimes cannot be changed.
It is important to constantly train all healthcare professionals on the intrinsic and extrinsic risk factors to implement prevention strategies including not only actions toward medications but also the rehabilitation of the functional capacity, education for self-care and increased surveillance of nurses in times and places with the highest number of falls, thus decreasing these adverse events and walking the path toward excellence in care.

Table 1 -
Number of risk levels and factors for patient falls and medication ordered.HURCG, Ponta Grossa, Paraná, 2013

Table 2 -
Therapeutic subgroups of ordered medications and levels of risk for patient falls, HURCG, Ponta Grossa, Paraná, 2013

Table 3 -
Levels of risk for patient falls on medication ordered at inpatient units, HURCG, Ponta Grossa, Paraná, 2013