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Standards › ASF Health Standards v10 › Standard 48

Standard 48

Falls, Pressure Injury and Safe Handover

Falls, pressure injury and safe handover: falls risk assessed and acted on, pressure injury prevented and staged, structured handover at every transfer, and events reviewed together for patterns..

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criteria
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documents
2
e-learning courses
8
references

Criteria on this page

48.148.248.348.448.5

How to read the colours
Red: Must. Required in every setting. Criteria that protect life are always red.
Green: Medium. Required, adapted to what a transition setting can realistically do.
Yellow: Minimum. The lowest acceptable level in a humanitarian setting, where resources are very limited.

Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.

Reference, not a requirement. Every policy, SOP, form and course on this page is a draft to help you. Adapt it to your hospital, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
48.1Falls Risk Is Assessed and Acted OnHumanitarian settings: MustTransition and fragile: MustStandard: Must

Every patient has a falls risk assessment on admission and after any change in condition. Patients at risk have a written prevention plan.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

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.

How the surveyor verifies this criterion

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.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Checks the criterion at each review Must

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
PSF-SOP-001 · Falls Risk Assessment and Prevention Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
PSF-FRM-002 · Falls Risk Assessment Tool Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Slip, Trip & Fall Prevention (FALL-01) Manager; Nurse

References

  1. NICE (n.d.). Falls: assessment and prevention in older people and in people 50 and over at higher risk. Used for: Falls risk assessment and prevention https://news.gmj.ge/guideline/falls-assessment-and-prevention-in-older-people-and-in-people-50-and-over-at-higher-risk/
  2. WHO (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Falls prevention across the life-course https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/
  3. WHO (2007). WHO global report on falls prevention in older age (2007). Used for: Falls prevention in older people https://news.gmj.ge/guideline/who-global-report-on-falls-prevention-in-older-age-2007/
48.2Pressure Injury Is Prevented in Patients at RiskHumanitarian settings: MustTransition and fragile: MustStandard: Must

Pressure injury risk is assessed on admission and at set intervals. Patients at risk receive a documented prevention plan, including repositioning, support surfaces and skin checks.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

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.

How the surveyor verifies this criterion

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.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Checks the criterion at each review Must

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
CLN-FRM-006 · Pressure injury risk and prevention record Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)
PRS-SOP-001 · Pressure injury staging, treatment and recording Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Slip, Trip & Fall Prevention (FALL-01) Manager; Nurse

References

  1. NICE (n.d.). Pressure ulcers: prevention and management. Used for: Pressure injury prevention https://news.gmj.ge/guideline/pressure-ulcers-prevention-and-management/
48.3Pressure Injuries Are Staged, Treated and RecordedHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Any pressure injury is staged with a recognised classification, treated under a written protocol, and recorded. Injuries that develop during care are reviewed.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

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.

How the surveyor verifies this criterion

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.

Staff responsible

Role Responsibility Level
Secretary (ISCO 3344) Keeps the Pressure injury staging, treatment and recording (PRS-SOP-001); pressure injury register Medium
Manager (ISCO 1342) Maintains the Pressure injury staging, treatment and recording Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
PRS-SOP-001 · Pressure injury staging, treatment and recording Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)
PRS-REG-001 · Pressure injury register Secretary (ISCO 3344) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Slip, Trip & Fall Prevention (FALL-01) Manager; Nurse

References

  1. NICE (n.d.). Pressure ulcers: prevention and management. Used for: Pressure injury staging and treatment https://news.gmj.ge/guideline/pressure-ulcers-prevention-and-management/
48.4Structured Handover Is Used at Every Transfer of CareHumanitarian settings: MustTransition and fragile: MustStandard: Must

A structured handover tool is used for every transfer of care. It covers the patient’s current condition, the risks, the plan and the responsible person, and it is confirmed by the receiving clinician.

Humanitarian settings
Must
Transition and fragile
Must
Standard
Must

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.

How the surveyor verifies this criterion

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.

Staff responsible

Role Responsibility Level
Nurse (ISCO 2221) Completes the Structured handover checklist Must
Manager (ISCO 1342) Checks the criterion at each review Must

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
HND-FRM-001 · Structured handover checklist Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344) Manager (ISCO 1342) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Handover & Communication for ASF Accreditation (MT-04) Manager; Nurse

References

  1. WHO (2020). Medication safety in transitions of care. Used for: Safe transfer of care and medicines https://news.gmj.ge/guideline/medication-safety-in-transitions-of-care/
  2. WHO (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: Safe handover and transfers of care https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
48.5Falls, Pressure Injury and Handover Events Are ReviewedHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must

Falls, pressure injuries and handover-related incidents are reviewed together at a defined interval. The review leads to written changes where a pattern is found.

Humanitarian settings
Minimum
Transition and fragile
Medium
Standard
Must

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

How the surveyor verifies this criterion

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.

Staff responsible

Role Responsibility Level
Manager (ISCO 1342) Maintains the Review of falls, pressure injury and handover events (HOV-SOP-001); incident learning log Medium
Manager (ISCO 1342) Checks the criterion at each review Medium

Documents: who does each step

Document Writes Approves Fills in Checks and signs Files and uploads
HOV-SOP-001 · Review of falls, pressure injury and handover events Manager (ISCO 1342) Chief executive (ISCO 1120) Manager (ISCO 1342) Chief executive (ISCO 1120) Secretary (ISCO 3344)

E-learning: who must take each course

Course Who must take it
Slip, Trip & Fall Prevention (FALL-01) Manager; Nurse

References

  1. WHO (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: Review of safety events https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/

Who is responsible for Standard 48

Each criterion names the positions responsible for it. Every position links to its own terms of reference.

Criterion Responsible Supports
48.1 Falls Risk Is Assessed and Acted On Head nurse / ward manager
Community / home care nurse
Occupational therapist
48.2 Pressure Injury Is Prevented in Patients at Risk Stoma and wound care nurse
Head nurse / ward manager
Community / home care nurse
48.3 Pressure Injuries Are Staged, Treated and Recorded Stoma and wound care nurse
Community / home care nurse
Head nurse / ward manager
48.4 Structured Handover Is Used at Every Transfer of Care Head nurse / ward manager
Emergency nurse
Triage nurse
48.5 Falls, Pressure Injury and Handover Events Are Reviewed Quality manager
Head nurse / ward manager
Clinical audit officer

Role details: reporting, supervision and training

Training shown is the general recommendation. Role-specific training is set in the next improvement round.

Role Reports to Supervises Recommended training
Quality manager Chief quality and safety officer Quality assurance officer, Patient safety officer, Accreditation coordinator, Clinical audit officer, Infection prevention and control (IPC) lead, Complaints and patient experience officer Facility induction; safeguarding adults (general recommendation)
Clinical audit officer Quality manager Medical records quality auditor Facility induction; safeguarding adults (general recommendation)
Head nurse / ward manager Director of nursing Nurse specialist, Registered nurse, Nursing associate, Health care assistant / nursing aide Facility induction; safeguarding adults (general recommendation)
Emergency nurse Head of department (per specialty) None Facility induction; safeguarding adults (general recommendation)
Community / home care nurse Head nurse / ward manager None Facility induction; safeguarding adults (general recommendation)
Occupational therapist Head of department (per specialty) None Facility induction; safeguarding adults (general recommendation)
Triage nurse Head of emergency department None Facility induction; safeguarding adults (general recommendation)
Stoma and wound care nurse Head nurse / ward manager None Facility induction; safeguarding adults (general recommendation)

Questions and answers

The criterion text is the authority. These answers summarise it.

Who does Standard 40 apply to?

Hospitals and inpatient services where falls, pressure injuries and handover between staff or services can cause harm.

What do the colours mean for this standard?

Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.

Is every patient assessed for falls?

Yes. Under 48.1 every patient has a falls risk assessment on admission and after any change in condition, and patients at risk have a written prevention plan.

How are pressure injuries prevented?

Under 48.2 pressure injury risk is assessed on admission and at set intervals, and patients at risk have a documented prevention plan.

How are pressure injuries recorded?

Under 48.3 any pressure injury is staged with a recognised classification, treated under a written protocol, recorded, and reviewed if it develops during care.

Is handover structured?

Yes. Under 48.4 a structured handover tool is used at every transfer of care and is confirmed by the receiving clinician.

Are falls and handover events reviewed?

Under 48.5 falls, pressure injuries and handover incidents are reviewed together at a defined interval, and changes are made where a pattern is found.

Guidelines for this standard

2 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.

  1. Classification and minimum standards for emergency medical teams (2021) (World Health Organization)
  2. Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course (World Health Organization)

Also relevant to this standard: