Standard 48: Falls, Pressure Injury and Safe Handover

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.

1. Every admitted patient has a falls risk assessment on admission.

Method. Check each sampled admission record for the assessment.

Evidence to show. Falls risk assessment and prevention (PSF-SOP-001, existing, reused); falls risk assessment tool (PSF-FRM-002, existing, reused).

Pass when. Every sampled admission has a documented falls risk assessment.

2. The assessment is repeated after any change in condition.

Method. Check the records of sampled patients with a change in condition for a repeat assessment.

Evidence to show. Falls risk assessment tool (PSF-FRM-002, existing, reused).

Pass when. Every sampled change in condition has a repeat assessment.

3. Patients at risk have a written prevention plan.

Method. Check each at-risk patient in the sample for a written prevention plan.

Evidence to show. Falls log (PSF-FRM-001, existing, reused).

Pass when. Every at-risk patient in the sample has a written prevention plan.

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.

1. Pressure injury risk is assessed on admission and at the set intervals.

Method. Check each sampled record for the admission assessment and the repeat assessments against the interval.

Evidence to show. Pressure injury risk assessment and prevention (CLN-SOP-004, existing, reused); pressure injury risk and prevention record (CLN-FRM-006, existing, reused).

Pass when. Every sampled record has an admission assessment and repeats within the interval.

2. Patients at risk have a documented prevention plan, including repositioning and support surfaces.

Method. Check each at-risk patient for the plan and the repositioning and surface entries.

Evidence to show. Pressure injury risk and prevention record (CLN-FRM-006, existing, reused).

Pass when. Every at-risk patient has a documented plan with repositioning and surface entries.

3. The prevention plan is carried out.

Method. Observe a sample of at-risk patients on a round and check the repositioning recorded.

Evidence to show. Pressure injury risk and prevention record (CLN-FRM-006, existing, reused).

Pass when. Repositioning is recorded at the planned times for every sampled patient.

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 staging, treatment and recording (PRS-SOP-001); 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. A structured handover tool is used for every transfer of care.

Method. Observe handovers on several shifts and check the records of a sample of transfers for the tool.

Evidence to show. Structured verbal handover (HOS-SOP-004, existing, reused); handover record (HOS-FRM-004, existing, reused).

Pass when. Every observed and sampled transfer used the structured tool.

2. 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.

3. 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); incident learning log (NET-REG-001, existing, reused).

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.

3. A pattern found leads to a written change.

Method. Check each pattern for the written change, its owner and its date.

Evidence to show. Root cause analysis of serious incidents (INC-SOP-001, existing, reused).

Pass when. Every pattern found has a written change with an owner and a date.

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.