Inpatient Falls: Improving assessment, documentation, and management.

Area of Science:

• Medical Safety
• Clinical Practice Improvement
• Healthcare Quality

Background:

• Inconsistent medical assessment and documentation of patients following falls by junior doctors were identified.
• A pilot audit revealed that 50% of expected data points were not recorded, potentially leading to missed injuries and prolonged hospital stays.

Purpose of the Study:

• To address inconsistencies in patient fall assessment and documentation.
• To improve the quality of care for patients who have experienced falls.

Main Methods:

• Implementation of a Plan-Do-Study-Act (PDSA) cycle.
• Provision of teaching sessions for junior doctors.
• Development and trial of a standardized fall pro-forma.
• Randomized review of 15-17 patient notes per cycle against National Patient Safety Agency (NPSA) guidelines.

Main Results:

• Documentation of fall history improved from baseline to 100% after interventions.
• Musculoskeletal examination documentation increased from 54% to 77%, reaching 100% with pro-forma use.
• The interventions demonstrated significant improvements in assessment and documentation quality.

Conclusions:

• Targeted teaching and a standardized pro-forma are effective in improving the assessment and documentation of patients following falls.
• The pro-forma has been integrated into hospital policy, becoming compulsory for managing patients post-fall.
• Future steps include ensuring pro-forma accessibility and re-auditing after revisions.