2242 Retrospective study of inpatient falls resulting in patient harm April–September 2023. Comparing our care to the BSG guidelines.

Abstract

Abstract Objective To identify good practices and highlight areas for improvement in the prevention and management of inpatient falls. Method Fifteen patients had serious inpatient falls between April and September 2023 within the hospital. Electronic notes and fall panel meeting minutes were used to provide an analysis of the ‘pre-fall’ and ‘post-fall’ assessments. Data was collected and analysed using AMaT and then compared to the standards set by RCP National Audit of Inpatient Falls (NAIF)—from KPI overview, 25% of patients had good quality Multi Factorial Risk Assessment (MFRA) in our Trust compared to National average of 33%. Results 70% of patients had been identified as high risk of falls at admission. Patients were prescribed a median of 10 medications, with a median of 3 falls-risk increasing drugs (FRID). Before the inpatient fall: the majority of patients received an ECG and mobility assessment early in admission. Only 40% of patients had a lying/standing blood pressure (LSBP) 100% of those that showed a deficit were acted on appropriately. Only 20% had a documented medication review. Following the inpatient fall: A LSBP was done in only 33% of patients. A medication review was completed in 53% yet the average patient was discharged with 3 more medications. 73% of patients suffered fragility fractures due to the fall however bone protection was only considered in 40%. Conclusion This audit highlights that there are areas of MFRA that require improvement, specifically LSBP, and a medication review. 33% of falls occurred in ‘medically-optimised’ patients—resulting in at least 60 additional inpatient days. The results have been discussed with the multi-disciplinary team—intervention to improve performance will be piloted in two areas with the highest incidence of inpatient falls, with continuous learning and sharing of lessons embedded into our Falls Collaborative Initiative.