Appendix B2: Tracking Record for Improving Patient Safety TRIPS (Text Description)

The Falls Management Program Manual

Name: __________________________               Medical Record Number:_______________________

Section A

Date of Incident ________________________           Time of Incident ______________  __  AM  __  PM

Day of Week
__ Sunday
__ Monday
__ Tuesday
__ Wednesday
__ Thursday
__ Friday
__ Saturday

__ Patient room
__ Patient bathroom
__ Another patient room/bathroom
__ Hallway
__ Dining room/day room
__ Shower/tub room
__ Outside building
__ Other (specify): ____________

Severity Level (check highest level of injury)
__ No injury
__ Minor injury/first aid only (ex: bruise, abrasion, skin tear)
__ Major injury (ex: laceration with suture, closed head injury, fracture)
__ Death

Treatment (check all that apply)
__ To primary care provider for evaluation
__ To emergency room
__ Admit to hospital
__ Sutures
__ X-ray
__ Blood work
__ Urinalysis
__ Other (specify): _________________

____Physician notified
Name of MD __________________________________
Date of notification _____________________________
Time of notification _____________________________
____Family/POA notified
Name of contact _______________________________
Date of notification _____________________________
Time of notification _____________________________
____Medical record flagged and occurrence documented accordingly
____Plan of care updated
____Medical record flagged for followup documentation

Signature: __________________________________________________   Date: ___________________

Section B

  1. Was the incident:

    __ Found on the floor (unwitnessed)
    __ Fall to the floor (witnessed)
    __ Near fall (patient lowered to floor by staff/other or stabilized)
    __ Self-reported fall

  2. The cause of the incident was:

    __ Lost balance
    __ Slipped (specify): ___________________
    __ Lost strength/weakness
    __ Tripped
    __ Lost consciousness/seizure
    __ Equipment malfunction (specify): ______
    __ Environmental factor (specify): ________
    __ Other (specify): ___________________

  3. The activity during the incident was:

    __ Ambulating in bedroom
    __ Ambulating to/from bathroom
    __ Transferring on/off toilet
    __ Sliding out of wheelchair
    __ Getting up from chair/wheelchair
         __ Brakes unlocked
    __ Getting in/out of bed
         __ Bed wheels unlocked
         __ Out of low bed to floor/mat
    __ Changing clothes/other ADLs
    __ Getting in/out of tub or shower
    __ Reaching for something
    __ Other (specify): ___________________

  4. Was there staff present during the activity?

    __ Yes      __ No

  5. The footwear at the time of the incident was:

    __ Shoes
    __ Slippers

    And if applicable
          __ No tread or tread too high/thick
          __ High/narrow heel
          __ Poor fit/loose
    __ Plain socks only
    __ Nonskid socks
    __ Bare feet
    __ Other (specify): __________________

  6. Indicate aid in use at the time of the incident:

    __ None
    __ Cane
    __ Wheelchair
    __ Walker
    __ Merry walker
    __ Hip protectors
    __ Other (specify): ___________________

  7. Part A.
    Was a restraint in use at the time of the incident?

    __ Yes (complete Part B)
    __ No

    Part B.
    __ Vest/trunk restraint
    __ Wrist/hand mitten
    __ Seat belt/roll belt/waist restraint
    __ Gerichair with table
    __ Lap Buddy/lap tray
    __ Other (specify): ____________________

  8. Part A.
    Were the side rails up?
    __ Yes (complete Part B)
    __ No

    Part B.
    __ Full length side rails (2 full or 4 half rails on both sides of bed)
    __ Other side rails: ____________________

  9. Part A.

    Was alarm present?
    __ Yes (complete Part B)
    __ No

  10. Part B (check all that apply)
    __ Bed alarm sounded during event
    __ Bed alarm did not sound during event
    __ Chair alarm sounded during event
    __ Chair alarm did not sound during event
    __ Other (specify): ____________________

As a Result of This Incident

  1. Did the patient's mental status change?

    __ Yes          __ No

  2. Did the patient's level of consciousness change?

    __ Yes          __ No

  3. Was the patient's blood glucose level checked?

    __ Yes       __ No
    If yes, indicate: ___________________

  4. Was the patient's pulse checked?

    __ Yes        __ No
    If yes, indicate: ___________________

  5. Was the patient's BP taken? __ Yes  __ No

    If yes, indicate value: ___________/___________
    systolic          diastolic

    If postural BP indicated, record value:
    sitting ______ systolic/ ______ diastolic
    standing ____ systolic/ ______ diastolic

  6. Was the patient's temperature taken?

    __ Yes        __ No
    If yes, indicate value: _______________

    And check
    __ oral   __ rectal     __ axillary

  7. Part A. What was the incident outcome?

    __ Injury (complete Part B)
    __ Noninjury

  1. Part B. If injury, indicate site(s) injured in first column, and the type of injury for each site checked ("X" all that apply):
 Left or RightBruise, skin tear
or abrasion,
without suture
or closed
head injury
PainIf other,
specify type
of injury
Upper spine______________
Lower spine______________
Other site______________
Other site (specify):
  1. Was this person in the Falls Management Program at the time of the fall?
    __ Yes        If yes, send fax alert to MD.
    __ No          If no, consider enrollment in the Falls Management Program.
If necessary, please provide a brief narrative of this incident:

Confidential and privileged document prepared for quality assurance and management purposes.

Page last reviewed October 2014
Internet Citation: Appendix B2: Tracking Record for Improving Patient Safety TRIPS (Text Description): The Falls Management Program Manual. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.