[Risk Management and analysis of an adverse event: accidental patients falls]

The matter of safety of operators and users within health care is becoming more and more topical. The relationship between users and operators with the health structures is a very relevant and expensive circumstance. For this reason some years ago a new culture for clinic risk was born, called risk management (RM), its goal is to create prevention, which focuses on patients and on the risks they take at the moment in which they keep in contact with health structures. We have take into consideration the matter of accidental falls of hospitalized patients occurred in year 2003 at the Hospital of S. Croce of Fano (PU) and made a careful check of the report file prepared by the Health Management of the body mentioned. The unfavorable event we considered is resulted to be of modest entity (0,56% of falls on the total amount of patients hospitalized) uniformly distributed all year long. The most involved patients were male, almost all hospitalized in General Medicine and Geriatrics ward. Most of all individuals fallen down did not produce particular effects. The falls happened commonly during night. Patients who fell down are completely or partially self-supporting. Through a study of all data we collected we defined two variants which interact: on one side the quality of medical assistance, the nurse assistance in particular, and the characteristics of patients fallen down on the other side. Literature too confirm our statements and underline the need to identify the danger points to define the subjects in risk of fall. We found relevant under the present health background to focus our attention on health risks, in particular the accidental fall in hospitals, which has to be considered an important event carry out the monitoring the quality of health assistance.