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Published on: August 1, 2017
[Analysis of fall reports from 20 university hospitals in Germany and Austria - Findings and recommendations]
Stefan Köberich1, Hannah Pinnekamp2, Marion Baltes3
1Pflegedirektion, Stabsstelle Klinisches Qualitäts- und Risikomanagement Pflege, Universitätsklinikum Freiburg, Freiburg, Deutschland.
Background:
Patient falls are among the most common adverse events in inpatient care settings and represent a significant risk, particularly for older and multimorbid patients. The standardized documentation of fall incidents using fall incident reports plays an important role in internal quality assurance and in legally required clinical documentation. Despite existing recommendations, it remains unclear how these recommendations are implemented at university hospitals in Germany and Austria.
Methods:
As part of a document analysis, 21 blank fall incident report forms from 20 university hospitals were analyzed. The analysis followed a deductive-inductive approach using a predefined, structurally logical process model of a fall event, including the domains Before the Fall, The Fall, Immediately After the Fall, and After the Fall. Items were categorized and descriptively analyzed.
Results:
A total of 378 items were identified across 15 categories and 18 subcategories. Items addressing the time, location, and circumstances of the fall were comprehensively included in all report forms. Fall risk factors, preventive measures, and post-fall consequences-such as adjustments to prevention strategies or informing relatives-were only addressed in some of the forms.
Conclusion:
The fall incident reports used at university hospitals show substantial variability in content and only partially reflect the overall fall process. This contrasts with recommendations issued by relevant professional societies and patient safety organizations. The findings suggest that the development of a consensus-based, process-oriented minimum dataset for fall documentation at university hospitals in German-speaking countries is warranted from a nursing science perspective. In addition, structured multidisciplinary post-fall debriefings offer a promising team-oriented approach for reflective engagement with fall events and for sustainably strengthening the culture of patient safety.
