Staff Fact Sheet
National Standard 10: Preventing Falls and Harm from Falls
John Children’s Hospital Hunter Hospital (JHCH) / Community Child & Youth Health
(CCYH)
The intention of this standard is to reduce the incidence of patient falls and minimise harm from falls.
Leadership and Structure
Children, Young People and Families Executive provide the leadership and governance in Clinical Quality
and Patient Care. Falls are reported & reviewed at the JHCH and CCYH CQ&PC Committees. These
committees report to the CYPFS Executive & District CQ&PCC which reports to HNE CQ&PCC.
Falls is an agenda item of quality and safety within team and service level meetings. Incidents relating to
falls are recorded in IIMS and significant risks are recorded in IRMS. They are monitored as part of a
manager’s accountability meetings and 90 day action plan.
The key governing directive is from the CEC NSW Falls Prevention Program
Currently the Paediatric Falls Prevention Program is being rolled out across JHCH and adapted for CCYH.
Partnering with Consumers
Patients and carers should be involved in the initial falls risk assessment and in the development of falls
prevention and management plans for at risk patients. Patients and carers should also be included in
reviewing the effectiveness of their falls prevention plan during hourly rounding and during clinical
handover/communication.
Information brochures on falls risks and prevention strategies must be available for at risk patients.
We need to be open and transparent about falls with our patients, parents and carers. Falls reports are
also reviewed at the CYPFS Family Advisory Council.
All units must display their days since last fall on the unit and this must be updated daily and after any
patient fall.
Required Training
All Nursing and Allied Health staff are required to complete the current face-to-face training:

Falls risk: screening and assessment and management plans for children and young people
(Relevant HETI on-line training is under development)
Implementation: What you need to know & do
All patients must be screened on admission and when their condition changes using the Paediatric Falls
Risk Assessment and a management sticker in the medical record highlighting the falls risk plan for all staff
involved in the care of the patient.
Patients identified at risk of falls must then have a Paediatric Falls Risk Assessment (SMR060.020) action
plan developed in partnership with patient and carer and strategies implemented.
Discharge plans/summaries and referrals are to include falls risk if identified during admission
All falls are to be reported in IIMS and the patients falls risk is to be re-assessed and a medical review
conducted.
At the beginning of each shift unit managers are to review all new ‘falls’ IIMS and to speak with the patient
/carer and ensure strategies are in place to prevent further falls.
A Reportable Incident Brief must be written with the Clinical Practice Improvement Coordinator- Camilla
Askie within 24 hours for all patient and visitor falls, which are then sent to the Director CYPF- Trish
Davidson and then onto the CEO. All patient and visitor falls will have an initial classification in IIMs as a
SAC 2 until the investigation is undertaken.
With acknowledgement to Calvary Mater Newcastle and Melissa Harvey
Jan 2015
The falls incidents are reviewed monthly and reported quarterly to the JHCH & CCYH Clinical Quality and
Patient Care committee.
Audit/Assessments


Facility audit – conducted annually and actions are being addressed through JHCH & CCYH
Clinical Quality and Patient Care committee
Additionally Health Care Record audits must be completed as scheduled and action taken to
improve documentation in relation to falls as necessary
Evidence is the documentation that shows what we’re doing
Nursing and Allied Health managers need to be able to show surveyors
 Records of staff education %
 IIMS falls data – including regular review of data (quarterly/annual) and actions taken to improve
 Evidence of investigations with evidence of evaluation /completion of recommendations
 Audit results AND action plans showing evaluation of outcomes
 Any identified risks documented on traffic light reports and MAMs
 “Last fall” posters are up to date
 Health Care Record falls audit results and action plan showing evaluation of outcomes
Everyone needs to know and be able to demonstrate:
 How to look at the CEC NSW Falls Prevention Program site
 How to use the falls risk assessment tools
 How to use the falls documentation sticker
 How to access the Falls prevention patient/carer information sheet
For further information:
Liz Newham Clinical Practice Improvement & Innovation Unit
Elizabeth.Newham@hnehealth.nsw.gov.au
With acknowledgement to Calvary Mater Newcastle and Melissa Harvey
Jan 2015