1384 Learning from Falls: Reassessing and Developing a Sleep-Lab Specific Falls Prevention Protocol

Abstract Introduction Falls within healthcare facilities represent one of the most prevalent safety incidents, particularly among geriatric patients. While falls in the sleep lab are uncommon, they can result in serious injuries, impose financial burdens, and raise concerns for healthcare staff and patient families. The widespread adoption of home sleep apnea testing has shifted the in-lab study population toward greater medical complexity. Yet, fall incidents in the sleep lab and targeted fall prevention policies have not been systematically explored. Two recent fall incidents with injuries in our sleep lab prompted a collaborative initiative between the Sleep Medicine Section and Veterans Affairs Geriatric Research, Education, and Clinical Center (GRECC). A Continuous Quality Improvement (CQI) Task Force was established to reassess the sleep lab environment and revise existing policies. Report of case(s) The first incident involved an elderly male veteran undergoing an in-lab polysomnography for suspected REM behavior disorder. During the study, he declined to have the bedrails raised. While experiencing parasomnia during sleep, he fell from bed and struck the floor. The veteran was transferred to the Emergency Department, where imaging confirmed a hip fracture that required surgical intervention. The second incident involved another elderly male patient referred for sleep apnea evaluation, who took zolpidem to facilitate sleep. Unable to fall asleep immediately, he requested to watch television. An hour later, he requested assistance to use the restroom. While the sleep technician was disconnecting EEG leads, the patient abruptly stood and attempted to rush unassisted, falling backward and striking his head against a closet door. He was found transiently disoriented; imaging revealed a C2 vertebral fracture managed conservatively with a cervical collar. Conclusion Falls in the sleep lab remain underrecognized due to their infrequency and the rarity of serious injuries. Our CQI Task Force developed a “4E” framework focused on Environmental modification, Education enhancement, Emerging technologies integration, and Effective monitoring. This multidisciplinary approach integrates evidence-based fall prevention and pragmatic fall prevention strategies. Targeted sleep lab-specific fall prevention policies and the inclusion of these protocols in AASM sleep lab accreditation standards will likely enhance patient safety within sleep medicine. Support (if any)