Policy for the Prevention and Management of Adult In-Patients
at Risk of Falling or who have already Fallen
Version
9
Name of responsible (ratifying) committee
Patient Safety Working Group
Date ratified
17th July 2014
Document Manager (job title)
Clinical Nurse Specialist, Falls and Bone Health.
Date issued
13th August 2014
Review date
12th August 2016 (unless requirements change)
Electronic location
Clinical Policies
Related Procedural Documents
See section 8: References and associated
documentation
Key Words (to aid with searching)
Patient slips, trips, falls; falls prevention; adverse
incident; RIDDOR; serious incident requiring
investigation; SIRI; post fall actions; essential care of
the fallen patient; hip fracture; spinal injury; medical
falls assessment
Version Tracking
Version
9
Date Ratified
Brief Summary of Changes
Author
Various minor changes to ensure adherence to NICE
guideline CG161 (issued June 2013). Update of Hover
Matt/Jack guidelines.
J. Windsor / N.
Cole
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 1 of 30
CONTENTS
QUICK REFERENCE GUIDE ............................................................................................................. 3
1.
INTRODUCTION.......................................................................................................................... 4
2.
PURPOSE ................................................................................................................................... 4
3.
SCOPE ........................................................................................................................................ 4
4.
DEFINITIONS .............................................................................................................................. 4
5.
DUTIES AND RESPONSIBILITIES .............................................................................................. 5
6.
PROCESS ................................................................................................................................... 6
7.
TRAINING REQUIREMENTS ...................................................................................................... 9
8.
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 9
9.
EQUALITY IMPACT STATEMENT ............................................................................................ 10
10. MONITORING COMPLIANCE ................................................................................................... 10
APPENDIX A: Protocol for Essential Care following an Inpatient Fall................................................ 12
APPENDIX B: Knowledge and skills Competency Framework .......................................................... 27
APPENDIX C: Falls Link Champion Role .......................................................................................... 30
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 2 of 30
QUICK REFERENCE GUIDE
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 3 of 30
1. INTRODUCTION
The policy reflects the Department of Health standards regarding the need to take action to
prevent falls and reduce injury in older people.
Timely and effective assessment, treatment, rehabilitation, and preventative advice is integral
to any falls management strategy
Patient falls are one of the most frequently reported incident within Portsmouth Hospitals NHS
Trust (the Trust). Patients who have fallen prior to admission or who present to hospital
following a fall are at high risk of falling whilst an inpatient. Reducing the risks of these falls can
be achieved by comprehensive and systematic risk identification and positive co-coordinated
multidisciplinary management and intervention.
The evidence base and interventions contained in this policy are specific to patients 65 years
and over. However risk assessment and interventions may be applied to any group or setting
and to any fall, including those from a height.
2. PURPOSE
The purpose of this policy is to ensure that an integrated inter-professional approach is adopted
for the management of all patients age 65 and over who are at risk of falling or who have
already fallen, regardless of the height from which they have fallen. This will ensure that each
individual patient has an adequate falls assessment undertaken and an appropriate
management plan initiated and implemented. This policy will also apply to all patients aged 5064 who are identified by a clinician as being at higher risk of falling.
3. SCOPE
This policy applies to all permanent, locum, agency and bank staff of Portsmouth Hospitals
NHS Trust and the MDHU (Portsmouth), involved in the care of patients
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
A fall may be defined as an event whereby an individual comes to rest on the ground or
another lower level with or without loss of consciousness.
Falls Pathway: is the algorithm or flow chart that guides the patient journey from admission to
discharge
Fall Risk Assessment Tool (FRAT): a risk assessment tool used in the Emergency
Department and which forms part of the detailed falls assessment
Get up and Go test: a test of postural stability and lower limb strength whereupon the patient
is asked to get up from a chair without using the arms take a few steps, turn and return to sit
down in the chair.
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 4 of 30
Backward chaining: the preferred method of assisting an uninjured patient up from the floor
using a chair.
Bedside rails: are rails on the sides of beds, sometimes referred to as cot sides, side rails or
safety rails
Ultra low bed: (Hi/Lo bed): one that lowers to less than 30cm from the mattress to the floor
Falls Alarm: an early warning system that alerts staff when the patient attempts to stand
unsafely or leave the bed without assistance.
Root cause analysis: a framework for reviewing and analysing patient safety incidents to
identify and recommend areas for change.
5. DUTIES AND RESPONSIBILITIES
The Clinical Nurse Specialist for Falls and Bone Health - The CNS (Falls) is responsible
for:
 Leading the implementation of the patient falls policy throughout the Trust;
 Leading and coordinating an audit programme to monitor the effectiveness of the falls
policy
 Informing the “patient falls” element of induction and any other mandatory training
content of the Trust Essential Skills Matrix and delivering training, as required
 Chairing the Trust’s Falls Prevention Group.
 Ensuring the provision of quarterly reports to: the Patient Safety Working Group; and
the District Falls Strategy Group
Falls Champions are responsible for:
 Understanding and implementing the role as described in appendix C, under the indirect
supervision of the CNS (Falls) and the direct supervision of their line manager.
 Participating in the root cause analysis of falls within their ward.
Practice Development Nurses / Practice Facilitators are responsible for promoting and
ensuring incorporation of the falls competency-based training in ward based staff development
programmes: to support the implementation of the Falls Prevention Strategy throughout the
Trust
Medical staff are responsible for:
 Taking and documenting a falls history, including the assessment of falls and fracture
risk factors for all patients age 65 and over on admission and/or following a subsequent
fall and initiating an appropriate management plan.
 Conducting and documenting a full review of each patient following a fall, in a timely
manner. This will be dependant on the clinical status of the patient and may be
immediately following the fall or on the next routine ward visit.
 Liaising with all relevant staff with regard to identified risk factors and management plan.
Clinical Service Centre (CSC) Heads of Nursing are responsible for:
 Monitoring competency achievement and ensuring, through CSC training plans, that
competency-training needs are met
 Supporting line managers to release staff for training/meetings.
 Working directly with line managers to address issues raised by falls root cause
analysis action plans
 Ensuring regular representation of their CSC at the Falls Prevention Group
Line managers and professional leads are responsible for
 Agreeing competency levels for their area of practice with the CNS (Falls)
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 5 of 30






Agreeing competency levels for individuals and ensuring these are reviewed at annual
development plan meetings.
Supporting the development of staff to ensure they meet / progress their falls
competency achievement.
Releasing staff to attend training sessions/meetings to support competency
achievement.
Working directly with the Falls Link Champions to develop and implement action plans
resulting from the root cause analysis of falls
Reporting falls competency development progress to the Head of Nursing
Identifying training requirements across their area of practice and ensuring these are
addressed in annual training plans.
Registered nursing staff are responsible for:
 Undertaking and documenting a risk assessment for each patient age 65 and over on
admission and initiating the falls pathway if indicated by that assessment
 Liaising with all relevant staff with regard to identified risk factors
 Reassessing and documenting falls risk factors on a regular basis, as dictated by the
severity of the risk
 Reviewing risk factors if the patient sustains a fall and informing all relevant staff /
carers in a timely manner. Referrals to medical and therapy staff will be dependant on
the clinical status of the patient.
Patient Safety Working Group is responsible for receiving a quarterly report from the CNS
(Falls) on all matters relating to the Trust’s Falls Prevention Strategy together with appropriate
risk control measures to eliminate or reduce any identified risks. The Group will take any action
it feels appropriate in the light of that received report.
Trust Falls Prevention Group is accountable to the Patient Safety Working Group and is
responsible to the District Falls Strategy Group. The Trust Falls Prevention Group, through the
CNS (Falls) is responsible for providing quarterly reports to the Patient Safety Working Group
and the District Falls Strategy Group. The Fall Prevention Group will also link to the Clinical
Service Centre/Specialty governance groups and lead, inform and monitor the implementation
of the falls prevention programme across the Trust
District Falls Strategy Group: this multi–agency, district–wide strategic group representing
primary, intermediate and secondary care services is responsible for informing and guiding the
development of the Trust’s Falls Prevention Group in response to national and local drivers.
The District Group is also responsible for receiving a quarterly report from the CNS (Falls); in
her capacity as the Chair of the Trust Falls Prevention Group.
Falls Link Champions Forum is chaired by the CNS (Falls) and is accountable to the Falls
Prevention Group. This Forum will enable peer support and be a point of information exchange
and training in relation to the Falls Pathway implementation programme.
6. PROCESS
6.1 It is a requirement to ensure that each individual patient has an adequate falls assessment
undertaken and an appropriate management plan initiated and implemented. The evidence–
base and interventions contained in this policy are specific to patients 65 years and over.
However risk assessment and interventions may be applied to any group or setting and to any
fall, including those from a height
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 6 of 30
Patient admitted through the Emergency
Department
Falls assessment on Green falls form within 4
hours
Discharged
FRAT = 2 or
less: refer to
GP
Patient Admitted
Falls risk assessment undertaken within
6 hours
[Risk assessment can be found within
the nursing admission documentation]





FRAT = 3
or more:
refer to
specialist
falls
service
Patient placed on inpatient falls pathway if they have ANY of the following:
Is a falls related admission or has fallen in the last year
Urinary incontinence or frequency
Has confusion/ dementia/ delirium
Is visually impaired
Is worried about falling
Falls assessment and care
plan
ALL PATIENTS
ON FALLS
PATHWAY
to have bed rails
assessment
Therapist
referral, if
required
Patients with
nutritional
problems
must be
referred to
medical team
and dietician
Consideration
and
assessment for
special
equipment such
as ultra low
beds or falls
alarms must be
documented
Medical review
of falls risk
factors and
medication
review.
All patients and
families to be given
written information
Help the Aged
‘Staying Steady’ and
‘Healthy Bones’
PHT’s Falls
prevention and
About Bedrails
Patient MUST be reassessed and that
assessment documented if any risk
factors change or they sustain a fall.
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 7 of 30
Procedure to be undertaken following an inpatient fall see appendix A for detailed
protocol
Undertake an immediate clinical assessment / check for injury
Return the patient to bed / chair using ‘backward-chaining’ technique if
possible, or an appropriate method of transfer if an injury is suspected
Carry out a clinical assessment using ‘post falls checklist’ and yellow medical
actions sticker
Request a medical review of falls and fracture risk factors
Reassess falls risks and document in falls care plan
Request input of specialists (e.g. therapists, pharmacist)
Report as patient safety incident on Datix-web
6.3
If a patient is transferred
All information regarding a fall, or the potential for a fall together with management plans
must be communicated to receiving ward
6.4
On discharge
When a patient is discharged and requires additional or further falls assessment they must
be referred to relevant specialist care services, as appropriate. These may include:






A Falls Clinic
Physiotherapy
Occupational Therapy
General Practitioner
Social Services
Other specialist services as available
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 8 of 30
7. TRAINING REQUIREMENTS
7.1 Training forms part of the Trust’s Essential Skills and Training Requirements; as identified in
the Training Needs Analysis. It is included in mandatory Corporate Induction and in
Essential Updates
7.2 Staff attend classroom or ESR delivered Essential Update training every three years and
undertake refresher training in the intervening years as identified by their manager.
7.3 All training is recorded on the Electronic Staff Record (ESR) from which the Learning and
Development Team provide a monthly heat map to each CSC, to enable monitoring of
compliance
7.4 Compliance is further monitored through the CSC performance reviews with the Executive
Team
7.5 In addition
7.5.1
7.5.2
7.5.3
All Band 5 rotational physiotherapy staff (who are not employed by the Trust)
undergo a dedicated session during their first rotation in Medicine for Older
People, Rehabilitation and Stroke, Orthopaedics and General Medicine
Falls Link Champions will receive a quarterly update with regards to their Level 4
Competency.
All FY1 and FY2 medical staff receive mandatory falls training.
7.6 There will also be general raising awareness of falls prevention and any new initiatives
through:




Workshops and events guided and/ or undertaken by the Falls Prevention Group
Articles in the Trust magazine
Displays and information bulletins using the Trust intranet system
Participation in National Falls Awareness Week
8. REFERENCES AND ASSOCIATED DOCUMENTATION
External
 National Service Framework for Older People (Standard 6) 2001
 NICE Guideline - The assessment and prevention of falls in older people (CG161)
 NHS Litigation Authority, Risk Management Standards for Acute Trusts www.nhsla.com
 National Patient Safety Agency (2007) Slips, trips and falls in hospital: www.npsa.nhs.uk
 Patient Safety First Campaign (2009) The ‘How to’ Guide for Reducing Harm from Falls
www.patientsafetyfirst.nhs.uk
 American Geriatric Society, British Geriatric Society and American Academy of
Orthopaedic Surgeons Panel on Falls Prevention (2010). Guidance for the Prevention
of Falls in Older Persons, Journal of the American Geriatrics Society
 Cameron,I. Et al (2009) Interventions for Preventing Falls in Older People in Residential
Care facilities and hospitals. Cochrane Database of Systematic Reviews:
Internal
 Policy for the use of Bedside Rails for Adult Patients Bedside Rails
 Policy for the Prevention and Management of Workplace Slips, Tips and Falls.
 Policy and Protocols for Manual Handling Operations & People Moving and Handling.
 Health and Safety Policy
 Risk Assessment Policy and Protocol
 Policy for the Management of Adverse Incidents and Near Misses
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 9 of 30



Policy for the Management of Serious Untoward Incidents
Policy for First Aid at Work
Acute confusion and behavioural disturbance in the older person Link
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
10. MONITORING COMPLIANCE
As a minimum, the following elements will be monitored
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 10 of 30
Minimum requirement
to be monitored
Lead
Requirement to undertake
appropriate
risk
assessments: 100% of
patients who have fallen
will have had appropriate
risk assessments
Falls Link
Champion
Raising awareness. 95%
of feedback from Patient
Safety
and
Quality
Training Day will be
good/very good
CNS Falls
85% uptake of mandatory
training
Learning &
Development
Department
Business
Manager
Tool
1)
2)
Audit of all SIRI
reports
Random audit
of 25 medical
records where
patient fell but
no harm was
caused
Frequency of Report
of Compliance
Annually
Reporting arrangements
Policy audit report to:

Annually
Policy audit report to:

ESR
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Annually
Patient Safety Working Group
Lead(s) for acting on
recommendations
CNS Falls/ Falls Link
Champions
CNS Falls
Patient Safety Working Group
Policy audit report to:
 Patient Safety Working Group
Review date: (12/08/2016)
Page 11 of 30
CSC Heads of Nursing
APPENDIX A: Protocol for Essential Care following an Inpatient Fall
Protocol for Essential Care
Following an Inpatient Fall
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 12 of 30
July 2012
Contributors:
Clinical Nurse Specialist, Falls Prevention (document manager)
Lead Back Care Advisor
Health and Safety Advisor
Nurse Consultant, Emergency Care
Matron/Governance Lead, Emergency Dept
Practice Development Nurse, Trauma Orthopaedics and Rheumatology
Spinal Nurse Specialist, Trauma Orthopaedics and Rheumatology
Consultant Geriatrician
Consultant Geriatrician
Head of Risk Management and Legal Services
Matron, Hospital At Night.
CONTENTS
Page Number
Purpose and background
14
Policy Links
14
NSPA Rapid Response
15
Managing inpatient falls algorithm
16
Suspected spine or hip injury: up from floor procedure algorithm
17
Guidance sheet A: up from floor procedure for patient with hip injury
18
Guidance sheet B: up from floor procedure for patient with spinal injury
19
Medical assessment guidance sticker
20
Nursing post falls checklist
21
Hover Jack and Matt: quick guide
RSVP structured communication guide
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
22 - 25
26
Review date: (12/08/2016)
Page 13 of 30
Purpose of Protocol
This document has been produced in response to the Rapid Response Report issued by the National
Patient Safety Agency (January 2011) to ensure that all NHS organisations provide optimum care
following an inpatient fall. Portsmouth Hospitals NHS Trust reports 2,500 inpatient falls annually with
at least 40 patients sustaining serious injury including hip fracture, head and spinal injury.
This protocol draws together procedures and processes already active in the Trust and additionally
provides information on the safe use of the new flat lifting equipment.
Persons Affected
This protocol applies to all clinical staff and all patient groups.
Policy Links
Falls Policy (clinical)
http://www.porthosp.nhs.uk/Clinical-Policies/Falls%20Policy.doc
Manual Handling
http://pht/Departments/ohs/Manual%20Handling/generic%20handling%20techniques/I%20%20iv%
20-%20Hover%20Matt.doc
http://pht/Departments/ohs/Manual%20Handling/generic%20handling%20techniques/I%20%20v%
20-%20Hover%20Jack.doc
First Aid at Work
http://www.porthosp.nhs.uk/Health-and-Safety-Policies/First%20Aid%20at%20Work%20Policy.doc
Workplace slips trips and falls.
http://www.porthosp.nhs.uk/Health-and-SafetyPolicies/Workplace%20Slips%20Trips%20and%20Falls%20prevention%20and%20management.doc
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 14 of 30
Essential care after an inpatient fall
Issue
Each year around 282,000 patient falls are reported to the NPSA from hospitals and mental health units. A significant number of these falls
result in death, severe or moderate injury including around 840 fractured hips, 550 other types of fracture, and 30 intracranial injuries.
Evidence of harm
Analysis of patient safety incidents reported to the National Reporting and Learning System (in the 12 months prior to 25 March 2010)
indicates that around 200 patients with fractures or intracranial injury after a fall in hospital experienced some failure of aftercare. Problems
included:

delayed diagnosis of fractures, ranging from several hours to several days after the fall;

neurological observations not recorded at all or recorded at inadequate intervals, resulting in delayed diagnosis of intracranial
bleeding;

sling hoists used to move patients despite signs or symptoms of limb fracture or spinal injury;

delays in access to urgent investigations or surgery.
Reducing the risk of harm
When a serious injury occurs as a result of an inpatient fall, safe manual handling and prompt assessment and treatment is critical to the
patient’s chances of making a full recovery. This RRR aims to ensure that local protocols and systems help staff to consistently achieve this
For IMMEDIATE ACTION by all NHS organisations that have inpatient beds. The deadline for ACTION
COMPLETE is 14th July 2011.
NHS organisations with inpatient beds should ensure that:
1.
2.
3.
4.
5.
They have a post – fall protocol that includes:
a)
checks by nursing staff for signs and symptoms of fracture or potential for spinal injury before the
patient is moved;
b)
safe manual handling methods for patients with signs and symptoms of fracture or potential for
spinal injury*;
c)
frequency and duration of neurological observations for all patients where head injury has occurred
or cannot be excluded (e.g. unwitnessed falls) based on the National institute for health and Clinical
Excellence (NICE) Clinical Guideline 56: Head Injury;
d)
timescales for medical examination following a fall ( including fast track assessment for patients with signs
of serious injury, or high vulnerability to injury, or who have been immobilised).
Their post – fall protocol is easily accessible (e.g. laminated versions at nursing stations).
Their staff have easy access to clear guidance and formats for recording neurological observations using a 15 point version of
the Glasgow Coma Scale ( GCS) and that changes in the GCS that should trigger urgent medical review are highlighted.
Their staff have access at all time to special equipment (e.g. hard collars, flat lifting equipment, scoops)* and colleagues with
the expertise to use it, for patients with suspected fracture or potential for spinal injury.
Systems are in place allowing inpatients injured in a fall access to investigation and specialist treatment* that is equal in speed
and quality to that provided in emergency departments and conforms to NICE Clinical Guideline 56: Head Injury.
* Community hospitals and mental health units without the equipment or expertise may be able to achieve this in collaboration with
emergency services.
Further information Supporting information on this Rapid Response Report is available at
www.nrls.npsa.nhs.uk/alerts.
For further queries contact rrr@npsa.nhs.uk; Telephone 020 7927 9500
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 15 of 30
Managing In Patient Falls.
In Patient Fall
If spine or hip injury
suspected
Altered GCS / EWS
Immobilise pt or limb
Actual or Assumed head
injury / Unwitnessed
fall.
New confusion or worsening
of chronic confusion
following fall.
Fast bleep duty Dr and
H@N Nurse Practitioner for
immediate attendance
Ward Staff – Assess Patient / Nature of Fall
Immediate actions
Primary & Secondary survey ABCDE
Procedure as post fall checklist
Check GCS
Locate and retrieve nearest
Hover Jack equipment.
Refer to specific
guidance for assessment
& manoeuvre up from
floor
Resultant actions
Perform ECG
Check BM
Check Lying & Standing BP
Dipstick urine
Place Medical Assessment Sticker in medical notes
Witnessed Fall
WITHOUT
Visible Injury
and patient
stable
Monitor patient
Medical review
next routine
ward visit (if
within 12 hours)
>1
IN HOSPITAL
FALL:
IMMEDIATE
MANAGEMENT
* Nurse as close to
the nurses station
as possible.
* Review use of
bedrails.
* Consider hourly/
2 hourly rounding
*Consider using
low profiling bed
with crash mats or
position existing
bed to lowest
setting
*Consider nursing
on the floor on a
mattress (after
appropriate risk
assessment)
ONLY as a last
resort and with the
proviso this will be
reviewed as soon
as possible
* Review post falls
checklist/ falls care
plan with medical
team at earliest
opportunity
Witnessed Fall
WITH Visible
Injury and /
or general
deterioration
since fall
Medical
review within
30 minutes
Use RSVP
Daytime
Nightime
Blp
Unwitnessed
Fall
Fast bleep duty Dr and
H@N Nurse Practitioner for
immediate attendance.
Start or increase neuro obs
to 1/2 hrly. Confirm nurse in
charge/bleep holder aware
Unwitnessed
Fall WITH
Injury and
assumed head
injury.
Suspected
spine or hip
injury.
Urgent
medical
review within
15 minutes
Urgent
medical
review within
15 minutes
Urgent
medical
review within
5 minutes
Use RSVP
Use RSVP
Use RSVP
WITHOUT
visible injury
and assumed
head injury.
Refer to duty Dr
Refer to Hospital at Night Nurse Practitioner
1100 (Medical) bleep 1559 (Surgical)
IF ANY OF THE FOLLOWING
LOSS OF CONSCIOUSNESS
ASSUME C-SPINE INJURY IN PRESENCE OF A FACIAL INJURY
DIZZINESS / LIGHTHEADEDNESS / VOMITING
HEADACHE / HEAD PAIN or TENDERNESS
CHEST PAIN
ORTHOSTATIC HYPOTENSION
SUSPECTED FRACTURE (pain, swelling, deformity of joint or limb)
SIGNIFICANT HAEMATOMA / LACERATION (> 3 CM)
ON FULL ANTICOAGULATION (not DVT prophylaxis)
> 1 in hospital fall *
H@N Practitioners to observe / advise
H@N Practitioners to inform doctors of events/action
Refer to
separate
process guide
Medical
Review
(See medical
assessment of inpatient
fall – urgent actions
sticker)
IF YOU NEED
ADVICE ABOUT
FALLS
MANAGEMENT
CONTACT YOUR
WARD FALLS
CHAMPION or CNS
Falls & BONE
HEALTH (bleep
1363)
Ward staff
DOCUMENT ALL INTERVENTIONS WITH RATIONALE FOR
ACTION TAKEN – All staff
COMPLETE ADVERSE EVENT FORM.–Nurse in charge of care of
patient or witness to fall.
COMPLETE / REVIEW FALLS CARE PLAN- Nurse in charge of
care of patient.
HAND OVER INCIDENT TO ONCOMING SHIFT- All staff
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 16 of 30
Procedure for getting a patient up from floor with
suspected hip or spine injury
Patient falls
Community
Hospitals or other
satellite units ONLY
–Immobilise
patient if hip/ spine
injury
suspected:
call 999
Time line
1. Assess using post fall
checklist in falls care plan
Hip injury suspected.
Immobilise limb with
pillows
2. Assess for hip and spinal
injury (see guidance sheets).
Spine injury suspected.
Hold patients’ head still
and maintained in the
position found.
3. Locate and retrieve
nearest Hover Jack and Matt
Bleep on call Doctor
Locate PAT slide if spinal
injury suspected

Bleep 1170 (ED senior
nurse) Request hard
collar and scoop if spinal
injury suspected.

ED will send 2 staff to
coordinate log rolling
procedure (but at least 4
other ward staff will be
required).

Bleep on call Doctor

Spinal board also
available from ITU (E5/
DCCQ) xt 6035. Send 2
people to carry.
Up from floor using Hover Jack
and Matt (Not Matt if spinal
injury)
Clean and return equipment
promptly. Fill out AIR form
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Within 30 mins to
preserve tissue
viability
Review date: (12/08/2016)
Page 17 of 30
GUIDANCE SHEET A: How to safely manoeuvre a patient who has fallen
and sustained a suspected HIP
FRACTURE from floor to bed using the Hover
Jack and Matt.
Before moving the patient – Assess for:
 Pain in hip or groin

Shortening of affected leg

External rotation or obvious deformity

Spasms, numbness or tingling

Assume injury if patient is unconscious or unable to answer
If yes to any of the above then follow the procedure below
PROCEDURE

Primary & secondary survey completed

Assume a fracture until confirmed otherwise.

Request your own duty doctor or Hospital @Night Coordinator (bleep 1100) attendance; clearly state your
findings (use RSVP).

Community Hospitals & satellite units phone 999.

Administer adequate pain relief.

Promptly request nearest HOVER JACK & MATT and organise team member to collect as soon as
possible.

Keep the patient warm, offer reassurance.

Check the neurovascular observations of the limb.

Always tell the patient your intentions, informing all of the movement to be undertaken with clear
instructions so the team and patient are aware.

Help the patient adopt a comfortable position whilst waiting for the arrival of the Hover Jack equipment.

Aim to support the affected leg; this is often achieved by sliding a pillow under the affected leg which helps
relax the muscles around the upper leg. This aids the patient comfort and helps protect the heel from
pressure.

Carefully support the limb normally around the ankle and knee when positioning the pillow into place.

When inserting the Hover Matt advise the patient to roll onto their affected side with a pillow between their
legs as this helps control the hip movement to a minimum level.
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 18 of 30
1.1.
GUIDANCE SHEET B: How to safely manoeuvre a patient who
has fallen and sustained a suspected /actual SPINE INJURY from
floor to bed using the Hover Jack.
Before moving the patient – Assess for:




Neck/ back pain or tenderness
Restriction in movement
Loss of movement or weakness in trunk or limbs
Loss of sensation, electric shock type or burning sensation in trunk and limbs
Assume spinal injury if the patient is unconscious or unable to answer.

If yes to any of the above then follow procedure below
I
PROCEDURE

Primary and secondary survey completed. Assume fracture until confirmed otherwise.
Explain to the patient why and what you are about to do. Keep the patient warm and offer reassurance
throughout.
Manually immobilise (head hold) immediately in the position in which the patient was found.
Request your own duty doctor or Hospital @Night Coordinator attendance (bleep 1100); clearly state your
findings (use RSVP).
Community Hospitals and satellite units phone 999.
Locate PAT SLIDE
Get HARD COLLAR, SCOOP STRETCHER & HOVER JACK from Emergency Dept (bleep 1170) 2 x ED staff will
attend to support and direct manoeuvre Or Orthopaedic Bleep holder (bleep 1372) Or spinal board also available
from ITU (E5 / DCCQ) ext 6035 – send 2 people to carry
Continue head hold whilst other assessments and interventions are carried out, this will be led by the medical and
ED team.
The patient should be placed in neutral alignment (continue to assist by head holding)
 Nose, sternum and symphysis pubis in line.
 shoulders and hips equally horizontal

Neck neutral position slightly flexed with no rotation.
DO NOT proceed to any further movement until the hard collar is fitted

Log roll onto scoop stretcher / spinal board this will be led by the ED or medical team and will require a
minimum of 4 people

Once in the scoop stretcher “triple immobilise” head
Hard collar fitted
Side supports .iv fluid bags or sandbags place either side of head
Tape secured to stretcher sides across the forehead
Tape secured to stretcher sides across the chin.
Continue with hover Jack manoeuvre support with head hold and triple immobilisation throughout transfer USE
PAT SLIDE FOR LATERAL TRANSFER ONTO HOVERJACK NOT HOVERMATT
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 19 of 30
It is expected that a medical review will take place following a patient fall. This may be carried out immediately
after the event to identify injury or new illness and cause of the fall or, if the patient is uninjured, may occur at
the next routine ward visit (if within 12 hours).
The medical review should be undertaken, whenever possible, by the team responsible for the patient: whether
in or out-patient. This includes falls that may occur while the patient is receiving treatment or investigations
away from the ward/ department.
For Day Surgery Unit, Theatre Admissions and Preoperative Assessment, the on call team for the surgical
team/specialty should be contacted to review the patient. If the fall occurs in theatre or recovery the surgical
team responsible for the patient should be contacted on D/E level. If the fall occurs in the holding bays in the
theatre suites, the surgical team for the procedure should be contacted or if unavailable the on call team for
that specialty.
The yellow sticker above is to be placed in the patient’s medical records and the assessment and action plan
documented underneath. Each ward/department has been issued with a supply of stickers and more can be
ordered from Medical Illustration ext 3387.
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 20 of 30
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 21 of 30
Hover Matt
Patient assessment
*
Most patients may be laterally transferred with this
equipment, however, it is particularly useful for a patient
who:
 has been lifted from floor level with the Hover Jack
(see technique Iv)
 is ‘bariatric’
*However, the Hover Matt is not suitable to transfer
a patient with a spinal injury.
Ensure that this takes place where due regard has
been given to the patient’s dignity and privacy
Resources required
 the Hover Matt and air supply. These are generally kept with the
Hover Jack in a small, wheeled cart
 extension straps, which may also be in the cart
 slide sheets, if the patient is to be slid onto the Matt, rather than
rolled, for rescue from the floor
Areas which have Hover Matts:
ED, E5, E2, F1 and some Theatres and X-rays
Self competency:
Microsoft Word
Document
For each technique the handler must ensure that they apply the safer biomechanics which are:
1. adopt a wide base of support 2. keep the knees soft (slightly flexed) 3. keep the spine in an upright neutral position ( to avoid bending,
twisting and/or over-reaching) 4. keep close to the load 5. keep head up
The handler should also ask themselves the question:
‘are there any unsafe practices or controversial techniques which I should avoid when I undertake this task? (section K)’
Technique:
Lateral transfer using the Hover Matt (HM) – bed/trolley to trolley/bed
Two or more handlers are required dependent on the risk assessment
 roll patient to place HM under the patient (technique F i, iii). The patient must be aligned centrally on the Matt and must be
lying flat. Pillows, sheets and pads can remain in place under the patient
 loosely clip the maroon HM straps in place across the patient
 position the air supply at the end of the bed/trolley, ensuring that the electric cable reaches easily
 insert the air nozzle by clipping it in place and wrapping the Velcro flap securely in place
 fit extension straps, if required, to the Matt on the side nearest to the receiving surface
 bring receiving surface as close as possible and apply brakes
 a Patslide may be used if there is a large gap between the surfaces
 adjust heights so that the receiving surface is slightly lower
 turn on the air supply to inflate the HM. The air supply must remain ON during the entire transfer (the HM rapidly deflates
when the air supply is switched off)
 the handler(s) take hold of the extension straps
 a 3rd handler might be required eg. to stand at the far side if the side rail there cannot be raised or there is no side rail, to
manage any equipment (eg. ventilation tubes) or to be at the patient’s side to reassure them
 it is good practice for someone to ensure that the nozzle does not become detached, or put under strain, at any stage
 one handler to co-ordinate with a READY – STEADY – PULL command
 the handler(s) adopt a ‘walk stand’ position with their knees slightly flexed and on ‘pull’, holding onto the extension straps,
transfer their weight from their front leg to their back leg, and pull the patient slowly to half way across the surfaces
 and then repeat to pull the patient fully across onto the receiving surface
 re-position patient, if required, whilst the HM is still fully inflated
 ensure that the patient is centrally positioned over the receiving surface before deflating (this is particularly important when
transferring onto a narrow surface eg. a trolley or imaging table)
 turn off the air supply to deflate and unclip the straps
 remove the HM by rolling the patient (technique F i, iii) but please note that the Matt is radio-translucent and may be left in
place (deflated) during imaging
This equipment CANNOT be used in an MRI scanner without a special extension hose
These are general guidelines only, make yourself aware of the specific instructions for using the Hover Matt (and Jack)
and read the manufacturer’s instruction booklet
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 22 of 30
Hover Jack
Patient assessment
Any patient may be lifted with this equipment, however, it is
particularly useful for the following patients who:
 have fallen and cannot get themselves back up (see
techniques Hi ii) particularly those who are suspected of
having sustained an injury (if spinal injury suspected the
patient MUST be stabilised on a spinal board before this
equipment is used)
 are ‘bariatric’
Ensure that this takes place where due regard has been
given to the patient’s dignity and privacy
Resources required
 the Hover Jack and air supply. These are generally kept
with the Matt in a small, wheeled cart
 extension straps, which may also be in the cart, if the Hover
Matt is to be used
 slide sheets, if needed
Areas which have Hover Jacks:
ED, E5, E2, F1
Self competency:
Microsoft Word
Document
For each technique the handler must ensure that they apply the safer biomechanics which are:
1. adopt a wide base of support 2. keep the knees soft (slightly flexed) 3. keep the spine in an upright neutral position ( to avoid bending,
twisting and/or over-reaching) 4. keep close to the load 5. keep head up
The handler should also ask themselves the question:
‘are there any unsafe practices or controversial techniques which I should avoid when I undertake this task? (section K)’
Technique:
Up from floor level using the Hover Jack (HJ):
The HJ is an ideal piece of equipment for the rescue of a fallen person who cannot get back up from the floor unaided (see
technique H i) and/or who is suspected of having sustained an *injury (technique H ii).
The Hover Matt may then be used to transfer the person onto a bed or trolley (see technique I iv).
*If a spinal injury is suspected the patient MUST be stabilized on a spinal board before this equipment is used and, in general,
the Matt should not then be used for a lateral transfer.
Three or more handlers are required dependent on the risk assessment
 the deflated HJ is brought to the side of the patient and placed parallel to them, head to foot
 *please note the restriction on the use of this equipment for suspected spinal injury
 the deflated HJ can be placed under the patient by a) rolling them from side to side (technique F i - iii); b) inserting slide
sheets under them (technique D i) and sliding the patient onto the HJ; or c) placing the patient on the HM (technique I iv) and
inflating it to ‘hover’ them across onto the HJ
 if the HM is to be used for a lateral transfer, once the patient has been lifted with the HJ, then the deflated HM can be in place
on top of the HJ when it is positioned under the patient (* but not if a spinal injury is suspected)
 loosely clip the blue HJ straps in place across the patient
 once the patient is positioned on the HJ, with or without the HM in place, bring the air supply close to the foot end, ensuring
that the electric cable reaches easily
 screw the red plastic caps in place taking care not to cross-thread them
 inflate the HJ in sequence ‘1,2,3,4’ by holding the air supply up to each valve in turn, until there is a slight back pressure
 the fully inflated cells are firm enough to commence CPR , if required, at any stage of the ‘1,2,3,4’ sequence
 once all four cells are inflated the patient can be laterally transferred to a bed or trolley
 if the HM was in place from the beginning of this procedure it can now be used for the lateral transfer but be sure to unclip the
blue straps and attach the maroon HM straps (technique I iv)
 if the HM is not in place then undertake a lateral transfer with slide sheets and a Patslide (technique D ii)
 it is essential that the handlers ensure that the inflated HJ cannot move away from the bed or trolley during the
transfer. The HJ does not have brakes and might move if not kept in place
 deflate the HJ in sequence ‘4,3,2,1’ and it is easier to clean the HJ before it is deflated
 all 4 cells of the HJ do not always have to be inflated but must always be inflated from 1 upwards
This equipment CANNOT be used in an MRI scanner without a special extension hose
These are general guidelines only, make yourself aware of the specific instructions for using the Hover Matt and Jack
and read the manufacturer’s instruction booklet.
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 23 of 30
HOVERMATT and JACK PROTOCOL
A Hover Matt, Jack and air-supply is stored, in its own cart, in DCCQ.
It is owned by the Moving and Handling Advisory Team and Service and will be available, for short-term use
only,* to other users throughout the Trust by following this protocol.
Protocol for using Hover Matt and Jack stored in DCCQ
Process

Ring DCCQ on ext 6035

Ring MHAS on ext 3642

Go to DCCQ to obtain the equipment

Return the equipment to DCCQ

Out of hours usage - ring DCCQ on ext
6035/6852 and ask to speak to nurse in
charge

If a fault is found with any part of the
equipment – take it out of use, label it to
alert others and report it to MHAS on ext
3642
Rationale

To ascertain whether the equipment is free to borrow

To ensure that a potential user is trained and competent
to use the equipment, or for MHAS staff member to
supervise its use during week days. DCCQ staff cannot
currently be responsible for this decision. In due course
other staff members will be trained and competent (e.g.
Orthopaedic staff) and will take this responsibility on
themselves, and the availability of this equipment to be
used elsewhere will, therefore, increase over the 24
hours.

To ensure that the equipment is signed out to a named
person who will take responsibility for its safe use and
adequate cleaning

To ensure that the equipment is safely returned, clean
and intact, and signed back in to DCCQ

Please contact Nurse in Charge only, as they will be
aware if equipment is free and will ensure a named
person will take responsibility for its safe usage, cleaning
and return to department for all to use

To ensure that the equipment remains in good working
order. The advice to contact MHAS to report a fault is
because this equipment is owned by them.
* If this type of equipment is required for long term use please discuss options with MHAS on 7700 3642
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 24 of 30
RESCUE FROM THE FLOOR
Quick Reference Guide
You MUST ensure that you are familiar with
the Trust protocol: ‘Essential Care
Following an In-Patient Fall’
You must be competent to use this equipment
if you are taking the lead
Using this equipment
Ensure that all the following are in the cart:
 Matt

Jack

Air supply
Ensure that you are happy that it is safe for
your patient to be moved with this equipment
Particularly be aware of the process should a
spinal injury be suspected
Decide how you are going to position the
equipment under the patient
Are you:
1. Rolling the patient so that the deflated Matt
and Jack are put in place - much as you
would change a sheet?
2. Rolling the patient to position the Matt and
then using the inflated Matt to move the
patient onto the Jack?
3. Using the slide sheet(s) and/or Patslide to
slide the patient onto the deflated Matt and
Jack?
Raising from the floor
1.
Clip safety straps in place
2. Ensure the red caps are screwed in place
securely
3. Hold the air supply onto the inlet valves on
the Jack to fully inflate. This MUST be in a
‘1,2,3,4’ sequence
4. Once raised, fix the air supply to the Matt
and transfer the patient to a place of safety
e.g. bed or trolley
5. DO NOT turn off the air supply to the Matt
until you are certain that the patient is
centrally positioned on the surface of the
bed or trolley
Finally
Unscrew the red caps to let the air out
Clean all the equipment and return it to the
cart
Return the cart and contents from where it was
borrowed
Adult Falls Policy: Issue Number 9. Issue Date 13/08/2014
Review date: (12/08/2016)
Page 25 of 30
RSVP Structured communication guide
Reason:
It’s ……………….on ward………………
I’m calling about (patient’s name)
The reason I’m calling is………………..
Story:
Reason for admission
Relevant history
Immediately preceding events
Vital Signs:
Heart rate………. BP……….. RR…………. CRT……...
SaO2………. FiO2…………. AVPU……….. Temp…….
EWS…………….. Urine Output…………. Gluc………...
Plan:
My plan is ……….
What investigations?
How often to monitor?
Parameters for action?
Prevention and Management of In-Patient Falls
(Review date: January 2014 unless requirements change)
Issue 8
Page 26 of 30
APPENDIX B: Knowledge and skills Competency Framework
Knowledge and skills Competency Framework
FALLS COMPETENCY FRAMEWORK
Name:
Dept / ward:
Competency Indicators
Core (All clinical staff)
Demonstrate understanding of your
responsibilities and role in relation to
patients who are at risk of falling or
who have fallen.
Be able to identify environmental
hazards and take action to eliminate
them and report actions to senior
staff.
Be able to follow the falls prevention
assessment and care plan under
direct supervision and report
changes to senior staff.
Explain the actions required to
ensure safe management if you are
the first responder to an individual
who has fallen.
Demonstrate knowledge of reporting
procedures following a patient fall
Be able to identify the Falls
Champion in your area.
Review date:
Competency Indicators
2 Level ( Support worker)
Competency Indicators
3 level ( Registered Nurse)
nd
As Core plus
Discuss the key factors that
contribute to patient risk of falling.
Be able to implement and evaluate
the falls management plan without
direct supervision.
Demonstrate effective
communication regarding falls
management when transferring or
referring care to another healthcare
professional or clinical area.
Demonstrate awareness of falls
reporting systems in your area and
contribute to the identification and
elimination of risk factors wherever
possible.
Demonstrate the effective and safe
use of falls prevention equipment
a) Ultra low beds
b) Falls Alarms
c) Falls Aware signs
d) Slippers and slipper socks
rd
As Core and level 2 plus
Discuss in detail the factors that
contribute to patient risk of falling
using the following categories:
a)
b)
c)
d)
Environmental
Functional
Physical
Clinical
Undertake and facilitate patient falls
assessment and action plan
development using:
a) Falls risk assessment in admission
document
b) Barthel index
c) Bedside rails assessment tool
d) MUST tool
e) Mobility and manual handling
assessments
Demonstrate active encouragement of
patient and carer / family to enable
them to contribute to the falls
management plan.
Demonstrate use of falls health
promotional material in accordance
with trust policy.
Prevention and Management of In-Patient Falls
(Review date: January 2014 unless requirements change)
Issue 8
Page 27 of 30
Competency Indicators
4th level (Falls Champion)
As Core, level 2,3 plus
Actively promote adherence to
appropriate falls management strategies
within ward / department.
Ensure that appropriate health
promotional material is available in ward /
dept.
Support staff initiatives in developing
effective falls management in your sphere
of influence.
Facilitate/ undertake audit of falls
management practice in ward /
department.
Critically review all falls incidents in
sphere of influence and implement
changes to reduce risks identified.
Liaison with the Specialist Falls Nurse to
share practice initiatives and maintain
current knowledge base for falls
management and risk reduction
strategies.
Competency Indicators
Core (All clinical staff)
Competency Indicators
2nd Level ( Support worker)
Demonstrate effective use of the
hoverjack and mat for patients
potentially injured following a fall.
Competency Indicators
3rd level ( Registered Nurse)
Competency Indicators
4th level (Falls Champion)
Discuss and demonstrate appropriate
management of any patient who has
fallen using the falls policy guidelines.
Liaison with multi-professional staff to
contribute to an integrated approach to
falls management.
Demonstrate use of appropriate
referral pathways for clients with
continuing or very high risk of falling.
Contribute to trust education and
development strategies to improve
management of falls risk.
Education resources to support Competency Achievement
Trust induction
Trust falls workshop, level 2
Trust falls workshop, level 3
Patient Safety and Quality Day
HCSW Induction
RN induction
Any 1hr update session arranged by
division
National occupational standards
framework for falls & osteoporosis at
www.skillforhealth.org
Level 3 competency checker
Trust falls policy (this policy)
Trust policy: Use of Bedside Rails
for Adult Patients.
Clinical Practice Guideline for the
Assessment and Prevention of Falls in
Older People (2007)
http://www.rcn.org.uk/__data/assets/pdf_fi
\\phthomes\
windsorj$\Meetings and groups\FLiC\Quick checkerle/0003/109821/002771.pdf?bcsi_scan_5
for level 3 falls competency.doc
87D43807B96E3A7=0&bcsi_scan_filena
Royal College of Nursing : Best
me=002771.pdf
Practice for Older People in Acute
Care Settings (BPOP): Guidance for
Nurses (2009)
http://nursingstandard.rcnpublishing.
co.uk/shared/media/multimedia/index
.htm
Trust policy for people moving &
handling
Age UK Preventing Falls Campaign
2010
http://www.helptheaged.org.uk/engb/AdviceSupport/HomeSafety/FallPr
evention/as_fallprev_030106_3.htm
Level 1
Regular attendance at the Falls Link
Champion Forum meetings
Level 2
The ‘How to’ guide for reducing harm from
falls.
www.patientsafetyfirst.nhs.uk
National Osteoporosis Society (2010)
www.nos.org.uk
Level 3
Level 4
Date:
Signature of Assessor
Date:
Signature of Assessor
Date:
Signature of Assessor
Date:
Signature of Assessor
Print Name
Print Name
Print Name
Print Name
Prevention and Management of In-Patient Falls
(Review date: January 2014 unless requirements change)
Issue 8
Page 28 of 30
Sources of Evidence to Support Competency.





Record of attendance of induction
Record of continued / updated professional development plan
Examples of individual falls core care plans
Examples of individual falls inpatient summaries
Examples of action plans arising from critical analysis of Adverse Incidence Reports
Updating Requirements:
Level 1 – initial within first 6 months of employ
Level 2 – Annual evidence of falls training received, CPD portfolio, IPR
Level 3 – Annual evidence of falls training received, CPD portfolio. IPR
Level 3 - Annual evidence of falls training received, CPD portfolio, IPR
Prevention and Management of In-Patient Falls
(Review date: January 2014 unless requirements change)
Issue 8
Page 29 of 30
APPENDIX C: Falls Link Champion Role
Person Specification and Falls Link Champion Role
Description
1. Be able to influence change within the workplace.
2.
Have keen interest in issues relating to falls and older people.
3. Have effective communication skills.
4. Ability to audit safe systems of work within the local area.
5. Ability to report findings of risk assessments to local managers.
6. Facilitate informal education sessions for new and existing staff.
7. Have a clear understanding of all policies and guidance issued by
the Trust relating to falls.
8. Be able to demonstrate effective problem solving within the local
area.
9. Be able to recognise own limitations and seek assistance from the
Specialist Falls Team when required.
10. Patient centred approach to falls assessment and management.
11. Be able to demonstrate falls risk identification, assessment and
management skills
12. Promote improving standards of quality of patient care.
13. Enhance, update and develop appropriate knowledge and skills.
Essential













The Role of the Falls Link Champion

Take the lead role for implementing PHT Falls Policy at ward level.

Ensure that all team members have received training in the completion and use
of falls documentation.

Attend all Falls Forum meetings or arrange for a suitably briefed deputy.

Ensure that the minutes / actions from each forum are cascaded to all
interdisciplinary team members in a timely and appropriate manner.

Ensure that all falls – related training received as a member of the forum or outwith this group is recorded in their own professional development portfolio and
relevant training record at ward level.

Act as a source of clinical expertise and education within their clinical area for the
assessment, intervention and management of patients who have fallen or who
are at risk of falling.

Take the lead role in working with the ward team to critically appraise quarterly
adverse event statistics and produce a plan of action as identified.
Prevention and Management of In-Patient Falls
(Review date: January 2014 unless requirements change)
Page 30 of 30
Desirable
Issue 8