Sentinel 6 Patient fall. Patient admitted with significant Fall mapping under way as part of Falls Prevention ‘hot-spots’ Subsequently found to and poor prognosis. hospital-wide Falls Prevention Project. Project ongoing have fracture. Patient Assessed as moderate risk on and added to All falls documentation and effectiveness of died following surgery admission. During admission falls risk organisation same under review. to repair fracture. increased and 15-30 minute check wide key protocol implemented. Patient had incidence and prevention standing agenda performance surgical repair of fracture on day after item at ward meetings. indicators. fall. Surgery successfully completed, Progress but patient condition deteriorated post monitored on a operation; died three days after the fall quarterly basis occurred. by Patient Safety Leadership Group. Serious 6 Patient fall resulting Patient fell whilst independently Review completed. sensor pad trialled with Falls prevention patient this worked well following event and in fracture. transferring from chair to bed. project ongoing – will be extended for other patients. and added to key performance indicators. Progress monitored on a quarterly basis by Patient Safety Leadership Group.
Sentinel 6 Patient fall. Subsequently found to have fracture. Patient died following surgery to repair fracture. Patient admitted with significant and poor prognosis. Assessed as moderate risk on admission. During admission falls risk increased and 15-30 minute check protocol implemented. Patient had surgical repair of fracture on day after fall. Surgery successfully completed, but patient condition deteriorated post operation; died three days after the fall occurred. Fall ‘hot-spots’ mapping under way as part of hospital-wide Falls Prevention Project. All falls documentation and effectiveness of same under review. incidence and prevention standing agenda item at ward meetings. Falls Prevention Project ongoing and added to organisation wide key performance indicators. Progress monitored on a quarterly basis by Patient Safety Leadership Group. Serious 6 Patient fall resulting in fracture. Patient fell whilst independently transferring from chair to bed. Review completed. sensor pad trialled with patient – this worked well following event and will be extended for other patients. Falls prevention project ongoing and added to key performance indicators. Progress monitored on a quarterly basis by Patient Safety Leadership Group.
SSE-cases-2010-11-FINALv1.docx