Introduction of a ‘Post fall assessment’ proforma improves management of patients following a fall in a rehabilitation setting

Abstract Background Falls are the most frequently reported incident within HSE services. 18,023 falls were reported in acute hospitals in 2021 and resulted in harm in 19% of cases. The HSE patient safety strategy has highlighted patient falls as a priority area for service improvement. One area where improvements could be implemented is the assessment of patients following falls. Methods A retrospective audit on medical note documentation of 40 patients following an inpatient fall was carried out, with areas for improvement identified. A multidisciplinary multi-part post fall assessment proforma with embedded guidance, based on best practice guidelines was subsequently introduced. A further retrospective audit was then conducted 6 months following its introduction. Results In cycle 1 of the audit, 67.5% of assessed patients did not have the presence or absence of ‘red flags’ documented. 27.5% of reviews did not record a detailed history and 7.5% did not have a formal focused examination documented. 32.5% of patients had a medication review undertaken. 20% of patients had a focused MDT review post fall. In cycle 2 the ‘immediate medical review’ section of the proforma was completed in its entirety in 95% of cases, including documentation of history, examination and ‘red flags’. A follow up review by the primary team, which included prompts to reconsider injury and consider risk reduction for future injurious falls was documented in 50% of cases. A focused review by the wider MDT took place in 75% of cases. Conclusion The introduction of a post fall assessment proforma has resulted in improved assessment for potential injuries and a more targeted approach to reducing the risk of future injurious falls.