%0 Journal Article
%T Understanding Design Vulnerabilities in the Physical Environment Relating to Patient Fall Patterns in a Psychiatric Hospital: Seven Years of Sentinel Events
%A Candy Carmel-Gilfilen
%A Margaret Portillo
%A Sara Bayramzadeh
%J Journal of the American Psychiatric Nurses Association
%@ 1532-5725
%D 2019
%R 10.1177/1078390318776086
%X BACKGROUND: The influence of the physical environment on patient falls has not been fully explored in psychiatric units, despite this patient population¡¯s vulnerability and the critical role of the physical environment in patient safety. AIMS: The research objective is to describe the spatial and temporal pattern of falls occurrences and their location in relation to the levels of safety continuum model. METHOD: This article presents an exploratory case study design. Seven years of retrospective data on patient falls, yielding 818 sentinel events, in an 81-bed psychiatric hospital in the United States were collected and analyzed. Data focused on extrinsic factors for falls, emphasizing the physical environment. Through a content analysis of the sentinel event narratives, recorded by the hospital staff, this study explored patient falls related to location and elements of the physical environment. RESULTS: The analysis revealed that 15% of recorded falls were attributed to some aspect of or element within the physical environment. The most typical locations of falls were patient rooms (39%), patient bathrooms (22%), and dayrooms (20%). Also, the results identified patterns of environmental factors that appeared linked to increasing patients¡¯ susceptibility to falls. Risk factors included poor nighttime lighting, flooring surfaces that were uneven, and spaces that inadvertently limited visual access and supervision. CONCLUSIONS: The physical environment plays an often-unexamined role in fall events and specific locations. These results are deserving of further research on design strategies and applications to reduce patient falls in psychiatric hospital settings
%K patient falls
%K psychiatric hospital
%K environmental design
%K evidence-based design
%K physical environment
%K work system
%U https://journals.sagepub.com/doi/full/10.1177/1078390318776086