Background: It is estimated that 3-5 falls occur per 1000 patient days in the US and UK(1). According to a study looking at National Database of Nursing Quality Indicators (NDNQI), established by the American Nurses Association, 26% of falls result in injury with 1 in 20 causing serious injuries(1). This poses a serious threat to patient safety and is a growing area of interest for hospital improvement initiatives. Hospital falls increase the cost of care, the length of stay, affect patient satisfaction and carry potential litigation risk(2). Comprehensive assessment and documentation after a fall is essential to determine potential risk factors, the etiology of the fall and early diagnosis of injuries. There is growing evidence that inadequate documentation impacts patient safety and increases legal risk(3-5). Furthermore, a lack of comprehensive assessment may lead to delay in diagnosis of injury. A review of our inpatient falls identified inconsistencies in provider assessment and a need to standardize documentation.
Purpose: To design and implement a comprehensive documentation template to help guide the assessment and management of inpatient falls amongst providers.
Description: We identified that standardized post-fall assessment and documentation is crucial to timely diagnosis of injuries from our review of fall cases at an urban tertiary care center. After a detailed review of literature and identifying risk factors for fall, we designed a standardized post-fall assessment template in our electronic medical record system EPIC ,aimed at improving provider documentation for falls in the hospital setting.The template includes time of assessment by the provider, description and potential causes contributing to the fall, medications that may increase fall or bleeding risk, whether the patient suffered head trauma, and history of dementia or cognitive impairment. In addition, the template prompts providers to document a detailed physical examination including skin, musculoskeletal and neurological examination, and the need for post-fall imaging and/or labs and further fall precautions. Educational interventions were conducted for hospitalists, advanced practice providers and housestaff to promote compliance with the post-fall assessment note. Post- intervention, we plan to review charts for inpatient falls on medicine wards, assess compliance and review data on falls with injuries and delay in diagnosis.
Conclusions: The goal of this initiative is to establish a standardized template for providers in the assessment and documentation of an inpatient fall, to support clinical decision making and improve patient outcomes.