Background We became aware, following an audit, that there were a number of patient falls in which the post falls assessment would have benefited from being more comprehensive. There is a risk that if someone is moved without being fully assessed for potential fractures or neurological damage, they may sustain further injury. Therefore, we embarked on a quality improvement project, with the aim of improving our post falls assessment.
For all staff to be aware of the correct procedure to follow after a patient falls.
To increase staff knowledge around their role in post fall management.
Reduce the risk of any harm.
The post falls assessment process was laid out using NICE guidelines.
Baseline measures were taken:
Doctors and nurses were given three scenarios and asked a set of questions
Documentation of previous falls was audited.
Post Falls Pathway was developed, introduced and placed in each room.
Bite size education was delivered.
Baseline measure was repeated, with the documentation of falls following the introduction of the pathway being audited.
Results The scenario scores increased from an average of 81.75% to 96.75%. The audit scores increased from 63% to 100%.
Conclusions A combination of the comprehensive guidance, including the Post Falls Pathway and staff education (including how to safely manoeuvre a patient after a fall), has demonstrated an increase in confidence and consistency of assessment and has reduced the risk of harm. Our approach has demonstrated that the introduction of the pathway has significantly improved the safe management of patients who have experienced a fall.
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