Standard 40: Falls, Pressure Injury and Safe Handover (Version 11)

Why it matters. Falls are among the most common harms in hospital, and they often happen when a patient’s condition changes. A falls risk assessment on admission, and after any change, guides the prevention.

Sample. Review falls risk assessments and falls records for a random sample of admitted patients in the last 3 months, and any patient with a change in condition.

Immediate fail (any one means the criterion is not met). An older patient with a previous fall is admitted with no assessment and falls at night, causing a fracture.

Why it matters. Pressure injuries develop in hours in a patient who cannot move. Assessing risk, and preventing it in those at risk, is one of the most reliable ways to avoid harm.

Sample. Review pressure injury risk assessments and prevention plans for a sample of patients at risk, in the last 3 months.

Immediate fail (any one means the criterion is not met). A bedbound patient with no repositioning record develops a stage 3 pressure injury during the stay.

Why it matters. A pressure injury must be classified, treated under a written plan and recorded. Without that, the next clinician cannot see how it is changing.

Sample. Review every pressure injury recorded in the last 12 months, with its staging and treatment record.

1. Each pressure injury is staged with a recognised classification.

Method. Check each recorded injury for its stage and the classification used.

Evidence to show. Pressure injury register (PRS-REG-001).

Pass when. Every recorded injury has a stage using a recognised classification.

2. Treatment follows the written protocol for the stage.

Method. Check each injury record against the protocol for its stage.

Evidence to show. Pressure injury staging, treatment and recording (PRS-SOP-001).

Pass when. Every injury has treatment that matches its stage in the protocol.

3. Injuries that develop during care are reviewed.

Method. Check the review record for each injury recorded as developed during care.

Evidence to show. Review of falls, pressure injury and handover events (HOV-SOP-001).

Pass when. Every injury that developed during care has a recorded review within 7 days.

Immediate fail (any one means the criterion is not met). A stage 4 injury is recorded as stage 2 with no protocol treatment, and it spreads to bone.

Why it matters. Each time a patient moves from one team to another, information can be lost. A structured handover tool, used every time, makes sure the important facts are passed on.

Sample. Observe handovers on several shifts and review handover records for a sample of transfers of care, in the last 3 months.

1. The handover covers the current condition, the risks, the plan and the responsible person.

Method. Check each sampled handover against the four items in the tool.

Evidence to show. Structured handover checklist (HND-FRM-001).

Pass when. Every sampled handover covers all four items.

2. The handover is confirmed by read-back.

Method. Check the record for the read-back confirmation on each sampled handover.

Evidence to show. Structured handover checklist (HND-FRM-001).

Pass when. Every sampled handover has a recorded read-back confirmation.

Immediate fail (any one means the criterion is not met). A patient at high falls risk is handed over without mention of the risk, and falls on the first night.

Why it matters. Falls, pressure injuries and handover failures often share causes. Reviewing them together shows the patterns that a single review would miss.

Sample. Review every falls, pressure injury and handover-related incident in the last 12 months, and the quarterly review records.

1. Falls, pressure injuries and handover incidents are reviewed together at the defined interval.

Method. Compare the review dates with the defined interval.

Evidence to show. Review of falls, pressure injury and handover events (HOV-SOP-001).

Pass when. Each quarter has a recorded joint review.

2. The review looks for a pattern across the events.

Method. Check the review records for the pattern analysis.

Evidence to show. Review of falls, pressure injury and handover events (HOV-SOP-001).

Pass when. Every review records the pattern analysis.

Immediate fail (any one means the criterion is not met). Falls on one ward cluster on night shifts for a year, and no one reviews them together with the handover records.