Tool 3O: Postfall Assessment for Root Cause Analysis

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care

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Background: A standardized approach to postfall evaluation is key to maintaining the patient's safety and for organizational learning about how to prevent future falls.

Reference: This tool is adapted from a tool developed by Ronald I. Shorr, MD, M.S. See Shorr RI, Mion LC, Chandler AM, et al. Improving the capture of fall events in hospitals: combining a service for evaluating inpatient falls with an incident report system. http://www.ncbi.nlm.nih.gov/pubmed/18205761 J Am Geriatr Soc 2008;56(4):701-4.) The Confusion Assessment Method within this tool is adapted from a tool by Sharon K. Inouye, MD, MPH (See Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion. Ann Intern Med 1990;113(12):941-8.)

How to use this tool: The information below can be customized for use within your hospital. Note that the tool was originally used as part of a dedicated fall evaluation service that was called to investigate each fall. For details, see the Shorr reference. This tool can be used by staff nurses and information systems staff.

The tool may be used for the purpose of root cause analysis to prevent future falls in this patient and in future patients. This assessment should be performed in conjunction with a medical provider's or pharmacist's assessment of medications contributing to fall risk (go to Tool 3I, "Medication Fall Risk Score and Evaluation Tools") and a medical provider's assessment of laboratory test results, if appropriate. The Orthostatic Vital Sign Measurement tool (Tool 3F) and the Delirium Evaluation Bundle (Tool 3J) may be helpful in completing this tool. A separate tool (Tool 3N, Postfall Assessment, Clinical Review) covers how to assess and follow injury risk immediately after a patient has fallen.

Postfall Assessment

1. PATIENT/WITNESS DESCRIPTION OF FALL:

1.1. Can you remember anything about your fall?

___ Yes        ___ No         The patient can't answer reliably

1.2. Did anyone witness the fall?

___ Yes, by: ___________________________________________________________________________________________

___ No or don't know (if no good quality patient or witness description, go to part 2)

1.3. Where did you fall?

___ Bathroom       ___ Hall       ___ Room  
___ Other, describe: ___________________________________________________________________________________________

1.4. What were you doing at the time of the fall?

___ Don't remember

___ "Rolled out of bed"

___ Trying to reach/pick-up something

___ Trying to get in/out of bed to go to toilet/commode

___ Trying to get in/out of bed for other reason

___ Trying to get in/out of chair

___ Trying to get on/off bedside commode/toilet

___ Trying to use sink, shower, chair, or toilet/commode

___ Trying to dress/undress

___ Other, describe: ___________________________________________________________________________________________

1.5. Why do you think you fell?

___ Don't know, remember

___ I had a recent lower extremity amputation

___ Slipped, tripped

___ Got lightheaded, dizzy, or "blacked out"

___ Arms or legs got weak

___ Tried to sit, but missed

___ I lost my balance

___ "Got tangled up" with IV, tubing, clothes, etc.

___ Bed or chair not locked

___ Other, describe: ___________________________________________________________________________________________

2. BRIEF MENTAL AND PHYSICAL ASSESSMENT

2.1. Short Portable Mental Status Questionnaire

* A mistake on ANY part of this question should be scored as an error.

Total Errors: _______

SCORING *:

0-2 errors: normal mental functioning
3-4 errors: mild cognitive impairment
5-7 errors: moderate cognitive impairment
8 or more errors: severe cognitive impairment

* One more error is allowed in the scoring if a patient has had a grade school education or less. One less error is allowed if the patient has had education beyond the high school level.

Section 2.1 adapted with permission from Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc 1975;23(10):433-41. ©E. Pfeiffer, 1994.

2.2. Confusion Assessment Method

Section 2.2 adapted from Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion. Ann Intern Med 1990;113(12):941-8. Used with permission, Sharon K. Inouye, MD, MPH ©2000, Hospital Elder Life Program. All rights reserved.

2.3. Severity of injury (check the most severe)

___ None (skip to question 2.5)

___ Minor (complaint of pain; requires ice, dressing, cleaning of wound, elevating of limb, or medication)

___ Moderate (requires suturing, steri-strips, or splinting)

___ Major (requires surgery, casting, traction, neurologic consultation for change in level of consciousness)

___ Possible, at time of this evaluation major injury is suspected but not yet confirmed by tests

___ Definite, at time of this evaluation major injury has been confirmed

___ Death

2.4. Describe injuries; check all that apply

2.5. Orthostatic blood pressure

* Sitting measurements are only necessary if standing cannot be obtained.

3. NURSE INTERVIEW (NURSE ASSIGNED TO PATIENT)

3.1. How did you find out that this patient fell?

___ I saw the patient fall

___ Alarm went off

___ Patient/witness called

___ Heard noise/found patient on floor

3.2. What was the patient doing at time of fall?

___ Don't know

___ "Rolled out of bed"

___ Trying to get in/out of chair

___ Trying to get in/out of bed to go to the bathroom/commode

___ Trying to reach/pick up something

___ Trying to get in/out of bed for another reason

___ Trying to get on/off toilet/bedside commode (BSC)

___ Trying to use the bedside sink, shower, toilet/BSC chair

___ Trying to dress/undress

___ Other, describe: ___________________________________________________________________________________________

3.3. Why do you think the patient fell/lost their balance?

___ Don't know

___ Catastrophic event (e.g., stroke, arrhythmia NOT orthostatic hypotension)

___ Arms or legs got weak

___ Got lightheaded, dizzy, or "blacked out"

___ Tried to sit, but missed

___ Secondary gain (e.g., seeking attention)

___ Related to recent amputation

___ "Got tangled up" in equipment

___ Low blood sugar

___ Slipped or tripped

___ Lost balance

___ Medications

___ Bed, chair not locked

___ Other, describe: ___________________________________________________________________________________________

3.4. Prior to the patient's fall, what was his/her activity level (ask nurse this question)?

___ Up ad lib

___ Ambulate with assistance

___ Bedrest

___ Up in chair with assistance

___ Other, describe: ___________________________________________________________________________________________

3.5. Prior to fall, identify the ancillary walking aids patient had available in room (check all that apply):

___ None

___ Cane

___ Walker

___ Wheelchair

___ Leg prosthesis

___ Other

3.6. Prior to fall, were fall prevention measures in place?

3.7. What CONNECTED IVs/tubes were present at the time of the fall?

4. OTHER IMPORTANT INFORMATION NOT COVERED ON THIS FORM

Please record orthostatic blood pressure readings in the patient's chart and return this form to the designated place in the staffing office.

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