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WSHA Post Fall Huddle Tool

The document provides instructions for conducting a post-fall huddle to understand why a patient fell, determine the immediate or root cause of the fall, and identify opportunities to prevent future falls. The huddle should involve clinical team members who know the patient and occur within 15 minutes of a fall. Factors like what the patient was doing and anything different about the situation are discussed. The team then develops a plan to modify the patient's care plan and protect from injury, considers system-wide learnings, and documents decisions.

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105 views2 pages

WSHA Post Fall Huddle Tool

The document provides instructions for conducting a post-fall huddle to understand why a patient fell, determine the immediate or root cause of the fall, and identify opportunities to prevent future falls. The huddle should involve clinical team members who know the patient and occur within 15 minutes of a fall. Factors like what the patient was doing and anything different about the situation are discussed. The team then develops a plan to modify the patient's care plan and protect from injury, considers system-wide learnings, and documents decisions.

Uploaded by

viziteu.emil
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Post-Fall Huddle Tool

Post-Fall Huddle Facilitation Instructions:


• Purpose: The huddle is to be a positive and safe learning environment to understand why the patient fell and
determine the immediate or root cause factor that caused the fall and if the patient was injured during the fall, what
was the immediate source of injury. The intent is for the patient/family and clinical care team to identify immediate
opportunity to prevent a recurrent fall (based on the same root cause) and injury.
• Participants: Three to four clinical team members, interdisciplinary when possible, who know the patient (unless the
patient’s condition is urgent or emergent upon rescue) and family if present.
• Guideline: Conduct the post-fall huddle after all patient falls whether unassisted or assisted, within 15 minutes, or as
soon as possible after patient care is provided.

Environmental and Interview Factors:


Utilize discovery to determine the root cause / immediate cause of the fall
What was the patient doing when the fall occurred?
(In patient’s words)
What was different this time?
• Ask patient what is different compared to prior
times when patient engaged in same activity?
(This question is only to the patient)

Strategy/Communication/Reliability:

Patient Care Plan


• What changes will we make in this patient’s plan
of care to decrease this patient’s risk for recurrent
fall based on the immediate cause of the fall?
• What injury reduction intervention will we make
to protect the patient from recurrent injury?

Shared Learning
• Is this a system-wide learning event?
• What patient or system problems need to be
communicated to other departments, units?
• How will we share?
Creating Accountability
• What are you implementing now?
• Is your implementation sustainable?

Inter-Professional Participants:
• Post-Fall Huddle Facilitator = _____________________________
• Check Participants in Attendance:
o Patient o Certified Nursing Assistant o Physical Therapist
o Family/Caregiver o Charge Nurse o Pharmacist
o RN assigned to patient o Provider o Occupational Therapist

2/14/2018
Decision Tree for Types of Falls:
(https://www.patientsafety.va.gov/professionals/onthejob/falls.asp)

Using the Decision Tree for Types of Falls (Circle One):

Accidental fall due Anticipated physiological fall Unanticipated physiological fall


Unsure
to environment due to known risk factors due to unpredictable factors

Submit this quality improvement tool to your fall prevention program coordinator. Use the tool to
address types of falls from a quality improvement and system-wide approach to learn, communicate
and educate in continuous fall prevention strategies.

What is your fall rate for? Also Consider:


o Accidental due to environment 1) Trending root causes of falls and injuries
o Anticipated physiological 2) Fall rate by type and injury rate by injury severity for:
o Unanticipated physiological o Clinical unit
o Population-based
o Age-stratified
o Repeat fall
o Recurrent faller

2/14/2018

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