Inpatient Falls: Improving assessment, documentation, and management.

2.50
Hdl Handle:
http://hdl.handle.net/11287/595553
Title:
Inpatient Falls: Improving assessment, documentation, and management.
Authors:
Nelson, Eleanor; Reynolds, Patrick
Abstract:
A frequently occurring job during on-call and out-of-hours shifts is reviewing a patient following a fall with this often being the responsibility of the most junior and inexperienced doctors. Following a pilot audit we identified inconsistencies in medical assessment and documentation, with 50% of expected data points not recorded. Failure to complete a thorough assessment can lead to missed injuries, prolonged length of stay, and litigation. Using the plan, do, study, act (PDSA) cycle model this project sought to address this through providing teaching to junior doctors and the development of a pro-forma. Three style cycles of data collection were performed; a formal baseline dataset, after delivering a teaching session to new junior doctors and following the trial of the new fall pro-forma. We selected 15 to 17 patient notes to review at random during a one month period for each data collection cycle and compared the medical assessment to the standards outlined by the National Patient Safety Agency (NPSA) guidelines.[1] There were two key areas of improvement identified following the teaching session and introduction of the proforma. Documentation of a fall history was improved by nearly 30% being recorded in 100% of cases after the interventions. Documentation of a thorough musculoskeletal examination was improved from being recorded in just 54% of cases to 77% of cases; it was recorded in 100% of the cases where the proforma was used. The project demonstrated the need to improve documentation and assessment of a patient who has fallen. Initial data collection has shown that assessment and documentation were improved providing teaching to junior doctors and by use of the document. The pro-forma has since been incorporated into hospital policy and now forms the compulsory documentation expected of the doctors and nurses managing patients following a fall. Ensuring easy access to the proforma and re-auditing after editing the document will be the next steps.
Citation:
Inpatient Falls: Improving assessment, documentation, and management. 2015, 4 (1): BMJ Qual Improv Rep
Publisher:
BMJ
Journal:
BMJ quality improvement reports
Issue Date:
25-Sep-2015
URI:
http://hdl.handle.net/11287/595553
DOI:
10.1136/bmjquality.u208575.w3781
PubMed ID:
26734426
Additional Links:
http://dx.doi.org/10.1136%2Fbmjquality.u208575.w3781
Note:
This article is freely available under Open Access. Click on the 'Additional Link' above to access the full-text on the publisher's site.
Type:
Journal Article
Language:
en
ISSN:
2050-1315
Appears in Collections:
2015 RD&E publications; Healthcare for Older People

Full metadata record

DC FieldValue Language
dc.contributor.authorNelson, Eleanoren
dc.contributor.authorReynolds, Patricken
dc.date.accessioned2016-02-04T11:54:37Zen
dc.date.available2016-02-04T11:54:37Zen
dc.date.issued2015-09-25en
dc.identifier.citationInpatient Falls: Improving assessment, documentation, and management. 2015, 4 (1): BMJ Qual Improv Repen
dc.identifier.issn2050-1315en
dc.identifier.pmid26734426en
dc.identifier.doi10.1136/bmjquality.u208575.w3781en
dc.identifier.urihttp://hdl.handle.net/11287/595553en
dc.description.abstractA frequently occurring job during on-call and out-of-hours shifts is reviewing a patient following a fall with this often being the responsibility of the most junior and inexperienced doctors. Following a pilot audit we identified inconsistencies in medical assessment and documentation, with 50% of expected data points not recorded. Failure to complete a thorough assessment can lead to missed injuries, prolonged length of stay, and litigation. Using the plan, do, study, act (PDSA) cycle model this project sought to address this through providing teaching to junior doctors and the development of a pro-forma. Three style cycles of data collection were performed; a formal baseline dataset, after delivering a teaching session to new junior doctors and following the trial of the new fall pro-forma. We selected 15 to 17 patient notes to review at random during a one month period for each data collection cycle and compared the medical assessment to the standards outlined by the National Patient Safety Agency (NPSA) guidelines.[1] There were two key areas of improvement identified following the teaching session and introduction of the proforma. Documentation of a fall history was improved by nearly 30% being recorded in 100% of cases after the interventions. Documentation of a thorough musculoskeletal examination was improved from being recorded in just 54% of cases to 77% of cases; it was recorded in 100% of the cases where the proforma was used. The project demonstrated the need to improve documentation and assessment of a patient who has fallen. Initial data collection has shown that assessment and documentation were improved providing teaching to junior doctors and by use of the document. The pro-forma has since been incorporated into hospital policy and now forms the compulsory documentation expected of the doctors and nurses managing patients following a fall. Ensuring easy access to the proforma and re-auditing after editing the document will be the next steps.en
dc.language.isoenen
dc.publisherBMJen
dc.relation.urlhttp://dx.doi.org/10.1136%2Fbmjquality.u208575.w3781en
dc.rightsArchived with thanks to BMJ quality improvement reports. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/en
dc.subjectWessex Classification Subject Headings::Eldery care.en
dc.titleInpatient Falls: Improving assessment, documentation, and management.en
dc.typeJournal Articleen
dc.identifier.journalBMJ quality improvement reportsen
dc.description.noteThis article is freely available under Open Access. Click on the 'Additional Link' above to access the full-text on the publisher's site.en
dc.type.versionPublisheden
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