Appendix B2: Tracking Record for Improving Patient Safety TRIPS (Text Description) The Falls Management Program Manual Name: __________________________ Medical Record Number:_______________________Section ADate of Incident ________________________ Time of Incident ______________ __ AM __ PMDay of Week__ Sunday__ Monday__ Tuesday__ Wednesday__ Thursday__ Friday__ SaturdayLocation__ 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)__ DeathTreatment (check all that apply)__ To primary care provider for evaluation__ To emergency room__ Admit to hospital__ Sutures__ X-ray__ Blood work__ Urinalysis__ Other (specify): _________________YesNo ____Physician notified Name of MD __________________________________Date of notification _____________________________Time of notification _________________________________Family/POA notifiedName of contact _______________________________Date of notification _____________________________Time of notification _________________________________Medical record flagged and occurrence documented accordingly____Plan of care updated____Medical record flagged for followup documentationSignature: __________________________________________________ Date: ___________________Section BWas 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 fallThe cause of the incident was:__ Lost balance__ Slipped (specify): _____________________ Lost strength/weakness__ Tripped__ Lost consciousness/seizure__ Equipment malfunction (specify): ________ Environmental factor (specify): __________ Other (specify): ___________________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): ___________________Was there staff present during the activity?__ Yes __ NoThe footwear at the time of the incident was:__ Shoes__ SlippersAnd if applicable __ No tread or tread too high/thick __ High/narrow heel __ Poor fit/loose__ Plain socks only__ Nonskid socks__ Bare feet__ Other (specify): __________________Indicate aid in use at the time of the incident:__ None__ Cane__ Wheelchair__ Walker__ Merry walker__ Hip protectors__ Other (specify): ___________________Part A.Was a restraint in use at the time of the incident?__ Yes (complete Part B)__ NoPart B.__ Vest/trunk restraint__ Wrist/hand mitten__ Seat belt/roll belt/waist restraint__ Gerichair with table__ Lap Buddy/lap tray__ Other (specify): ____________________Part A.Were the side rails up?__ Yes (complete Part B)__ NoPart B.__ Full length side rails (2 full or 4 half rails on both sides of bed)__ Other side rails: ____________________Part A.Was alarm present?__ Yes (complete Part B)__ NoPart 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 IncidentDid the patient's mental status change?__ Yes __ NoDid the patient's level of consciousness change?__ Yes __ NoWas the patient's blood glucose level checked?__ Yes __ NoIf yes, indicate: ___________________Was the patient's pulse checked?__ Yes __ NoIf yes, indicate: ___________________Was the patient's BP taken? __ Yes __ No If yes, indicate value: ___________/___________systolic diastolicIf postural BP indicated, record value:sitting ______ systolic/ ______ diastolicstanding ____ systolic/ ______ diastolicWas the patient's temperature taken?__ Yes __ NoIf yes, indicate value: _______________And check__ oral __ rectal __ axillaryPart A. What was the incident outcome? __ Injury (complete Part B)__ NoninjuryPart B. If injury, indicate site(s) injured in first column, and the type of injury for each site checked ("X" all that apply):INJURY SITETYPE OF INJURY Left or RightBruise, skin tearor abrasion,lacerationwithout sutureFractureLacerationw/suturesor closedhead injuryPainIf other,specify typeof injuryHead______________Neck______________Upper spine______________Lower spine______________Shoulder______________Arm______________Wrist______________Hand______________Chest______________Abdomen______________Pelvis______________Hip______________Leg______________Ankle______________Foot______________Other site______________Other site (specify):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. Current as of February 2010 Internet Citation: Appendix B2: Tracking Record for Improving Patient Safety TRIPS (Text Description): The Falls Management Program Manual. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanapb2txt.html
Back
