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Tool 5A: Information To Include in Incident Reports

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

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Background: The purpose of this tool is to audit incident reports of falls to see if the reports provide adequate information for root cause analysis. Alternatively, the information below may be used in conjunction with Tool 3O, "Postfall Assessment for Root Cause Analysis" to develop a template to be filled out when reporting a fall.

Reference: Adapted from National Health Service publication Slips, Trips, and Falls in the Hospital, available at www.nrls.npsa.nhs.uk/resources/?EntryId45=59821 .

How to use this tool: Review your last 10 incident reports for falls and see whether the information below is captured in the report. This tool should be used by the quality improvement manager. Information systems staff may also use this tool to develop or update electronic templates for submitting incident reports.

Use this tool to identify areas for improvement and develop educational programs where there are gaps.

Information To Include in Incident Reports

Examples of InformationReason To Collect This Information
Reporting factorsWitnessed/not witnessedMake a clear distinction between what was seen or heard and the patient's account of what happened.
Outcome of investigations recordedWhen patients are reported as having x rays or other investigations after a fall, the results of the x ray or other investigation should be included in the report.
Type of injuryBe specific, e.g., "fractured tibia," not "broken leg."
Environmental factorsBuzzer/bell available within reach before fallHighlight whether there is an issue about accessing call bells.
If a fall from bed, whether bedrails were in useHelp assess how bedrail use is affecting falls or injury.
Floor wet/dry/talcum powderReflect on cleaning regimen and need for nonslip surfaces.
FootwearIf problems with missing or unsuitable footwear are highlighted, organizations could develop systems for providing alternatives.
Walking aid in use/in reachIt may highlight bedside storage issues or access to walking aids for patients admitted in the evenings or on the weekend.
Patient factorsMental stateIdentify those patients most vulnerable to falls because of sedation, dementia, or delirium.
First fall this admission or repeat fallBalance resources between preventing initial falls and secondary prevention.
Days since admissionEnsure timescales for assessing and preventing falls are tailored to when falls are most likely to occur.
Medication affecting risk of fallsSedative and psychotropic medication, or medication with drowsiness as a side effect, may contribute to falls.

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Current as of January 2013
Internet Citation: Tool 5A: Information To Include in Incident Reports: Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool5a.html