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Topic Falls in hospital are the most common patient safety incidents reported in hospital trusts in England. In 2008/09, 283438 inpatient falls were reported to the National Patient Safety Agency. A significant number of falls result in death or severe or moderate injury, at an estimated cost of £15 million per annum for immediate healthcare treatment alone.
Reports show that a significant number of patients with an intracranial injury following an inpatient fall experienced some failure of aftercare leading to delays in access to investigations/surgery. Between October 2011-12, there were 1871 reported falls at Worcestershire Acute Hospitals NHS Trust - 44 resulting in serious harm.
Intervention In addition to education, a double-sided proforma was designed by a junior doctor covering all the necessary documentation in a tick box format. This was a distinctive colour for easy visibility and was made available following a teaching session and a public launch on all the inpatient wards. This prompted medical staff to complete the proforma and therefore take the relevant history and examination so to promptly identify those with risk of serious harm as a result of the fall.
Improvement 6 and 12 months later appropriate documentation and examination improved greatly. For example, documentation of loss of consciousness improved from 27% to 67%, limb weakness from 20% to 67% and drug history from 0% to 50%. Similarly significant improvements were observed in documentation of relevant examination findings – cranial nerve examination improved from 0% to 67%, limb neurological examination from 16% to 76% and signs of basal skull fracture from 0% to 83%. However, when this proforma was not used, documentation was very poor.
Discussion The introduction of a reminder sheet designed by junior doctors for junior doctors improved safety standards in the hospital and could have the same effect in any healthcare setting.