A patient, with a known falls risk, fell during a radiology exam and died from her injuries.

Key Lessons

  • Critical information about a patient’s risk status must be transferred during a transition of care.
  • Training that demonstrates the risks of not following certain policies may prevent dangerous deviations.

Clinical Sequence

A 55-year-old female with multiple co-morbidities (hypertension, Type 2 diabetes and on dialysis for end-stage renal disease) was admitted to the hospital with a diagnosis of osteomyelitis of the spine. She was treated with a course of antibiotics. Two months later, she returned to the hospital with worsening lower back pain. The patient’s daughter reported that her mother had been experiencing periods of instability and dizziness at home (the mother denied this). The nursing staff noted the patient as a high risk for falls.

A standing lumbar spine film to rule out spinal instability was ordered by a covering orthopedic resident. The nurse prepared a transfer checklist and placed it inside the chart (the hospital’s policy is to place this note on the front of the chart). A transporter wheeled the patient to Radiology, where she was received by a technologist with no verbal hand off given about the patient. The technician asked the patient if she was okay to stand, and she said she was. He helped her get into the right position for the film and stepped away to capture the image.

In the time he stepped away, the patient became unstable and fell. The technologist rushed to the patient who was now bleeding from the face and head and was disoriented. A code was called and the patient was stabilized. A head CT scan revealed right parietal intra parenchymal hemorrhage. She sustained facial fractures and exhibited left-sided hemiparesis.

The patient was admitted to the ICU. She was unable to swallow or recover mobility and required a percutaneous gastrostomy tube for feeding. Following transfer to a rehabilitation facility, the patient developed a Stage IV decubitus ulcer of her sacrum. After two years in a nursing home, the patient died.


The patient’s family filed a claim against the organization, alleging that there was a failure to ensure the patient’s safety resulting in a fall.


The case was settled in the high range.


Risk: The patient was an unreliable source of information about her stability.

Recommendations: Awareness of potential lapses in the patient’s memory or understanding of their illness might help clinicians avoid some errors when eliciting a patient's past medical history. Seek information from the patient’s current care provider and medical record to validate the patient’s response.

Risk: There was a lapse in information between the teams transferring and receiving the patient.

Recommendation: Human factors, such as stress, distraction, and communication problems, increase the risk of errors. This is especially true during transitions in care, which often prove to be a time when there may a loss of critical patient information. Mitigation of this risk includes using standardized handoff tools (e.g., I-PASS, SBAR) to assure all vital information is passed between care teams. Face-to-face or verbal handoffs should include read back of information to ensure it was accurately received. During the time of the handoff, interruptions should be limited to prevent distraction.

Risk: Documentation was done, but was not placed on front of chart per hospital policy.

Recommendation: Failure to follow policy and procedure may cause lapses in patient safety. The use of tools to prompt policy compliance may assist providers to follow policies that impact patient safety. In complex health care environments, the use of checklists can provide cues to improve clinicians’ reliability and consistency. Involving front line teams in the development of the checklists may increase buy in, and thus use, of such tools.


  1. Gawande, A. (2010). The Checklist Manifesto-How to Get Things Right. New York: Metropolitan Books.
  2. Starmer A, Spector N, Srivastava R, et al. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics. 2012; 129(2):201-04. doi:10.1542/peds.2011-2966
  3. Clarke D, Werestiuk K, Schoffner, A. et al 2012). Achieving the ‘perfect handoff’ in patient transfers. Journal of Nursing Management. 2012;20(5):592-98. doi: 10.1111/j.1365-2834.2012.01400.x. Epub 2012 Jun 19.
  4. Kaiser Permanente (n.d.) SBAR Toolkit. Institute for Healthcare Improvement.
  5. Leonard M, Lyndon A, Morgan J, Stone A.: Structured communication and psychological safety in health care audio broadcast. WIHI. 2014.

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