Section 1 - Information About the Patient/Visitor Fall

Patient Label

Post-Fall Huddle Directions: This form can be used for all falls. This analysis should be done ASAP after the fall, but less than 24 hr. This review should include staff involved in the patient/resident/visitor fall and the staff who found the fall and is facilitated by the Team Lead or Department Manager at the time of the fall. This report is not intended to place blame or serve for disciplinary action.

Section 1 - Information about the patient/visitor fall Date of Fall: Time of Fall: Unit where fall occurred: Location of fall within Unit:

Describe Event: Include patient /resident/visitor activity and symptoms at time of fall and just prior to fall.

How was the patient/visitor Describe the actual or suspected patient/visitor injury(s): evaluated/treated for injury?

Section 2 - What was the Fall Risk Assessment for this patient/resident prior to the fall? What was the patient’s fall risk score and level of risk prior to this Score: High Risk fall? Standard Risk I have no idea What was the date/time of the patient’s last fall risk assessment? Date______Time______NA Was fall risk assessment documented on: Admission to unit? Yes No N/A Q24h since admission? Yes No N/A Each change in level of care? Yes No N/A Has the patient/visitor had a fall in the past 3 months? Yes No N/A

Section 3 - What actions were taken to prevent this patient/visitor fall? Was the patient identified as a fall risk by Yes No N/A, non-inpatient units bracelet, sign on door & sticker on chart? If NO, explain: List interventions documented in the 24hr prior to Rounding schedule Sitter N/A the fall to prevent the fall/injury? Toileting schedule Family Assistance Bed alarm Pharmacist med review Restraints Fall Risk review w/ MD Bedside Commode Other______Is there plan of care documentation, if the patient is high risk for fall? Yes No N/A Identify factors that contributed to this patient/visitor fall (environment, staffing, toileting, patient cooperation, patient/resident monitoring, etc.)

D:\Docs\2018-04-04\063d43f09d2b7eb08e538e8cd4d2282a.doc Page 1 of 3 List medications administered to patient/visitor Is patient/visitor on anticoagulation therapy? in last 24 hrs that may have contributed to the Yes No fall? If yes, what is most recent anticoagulation lab value?

Given that hindsight is often beneficial for learning, what could have been done to prevent this fall?

What was implemented to prevent patient/visitor from falling again?

Manager follows up, obtains staff report.

Section 4 –List any other lessons learned from this fall

Staff involved in Post Fall Huddle:

______Date

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