TRIPS (Text Description)
Tracking Record for Improving Patient Safety
Name: __________________________ Medical Record Number:_______________________
Section A
Date of Incident ________________________ Time of Incident ______________ __ AM __ PM
Day of Week
__ Sunday
__ Monday
__ Tuesday
__ Wednesday
__ Thursday
__ Friday
__ Saturday
Location
__ 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): _________________
|
Yes |
No |
|
__ |
__ |
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
- 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
- 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): ___________________
- 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 __ No
- 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): __________________
- 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)
__ No
Part 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)
__ No
Part 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)
__ No
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
- Did the patient's mental status change?
__ Yes __ No
- Did the patient's level of consciousness change?
__ Yes __ No
- Was the patient's blood glucose level checked?
__ Yes __ No
If yes, indicate: ___________________
- Was the patient's pulse checked?
__ Yes __ No
If yes, indicate: ___________________
- 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
- Was the patient's temperature taken?
__ Yes __ No
If yes, indicate value: _______________
And check
__ oral __ rectal __ axillary
- Part A. What was the incident outcome?
__ Injury (complete Part B)
__ Noninjury
- Part B. If injury, indicate site(s) injured in first column, and the type of injury for each site checked ("X" all that apply):
INJURY SITE |
TYPE OF INJURY |
|
Left or Right |
Bruise, skin tear
or abrasion,
laceration
without suture |
Fracture |
Laceration
w/sutures
or closed
head injury |
Pain |
If other,
specify type
of injury |
Head |
__ |
__ |
__ |
__ |
__ |
__ |
__ |
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.
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