What have we learnt from recent Inpatient SIRI panels?
How can you use this learning to make your patients safer?
Quarter 1 2013-14 learning
Learning from Inpatient SIRI panels / What can you do tomorrow?1. Slippers
A patient wearing foam slippers fell and sustained a fractured hip. This may have been a contributory factor.
Foam slippers can pose a slip/trip risk and should be avoided. Slippers should be provided for any patient who has unsuitable footwear. / Remove all ward stocks of foam slippers.
Ensure your ward has a supply of slippers.
If a patient’s relatives cannot provide slippers or they cannot afford them, supply them via ward stock.
2. Bedrails
Bedrails left raised (accidentally) can pose a falls risk as confused patients may climb over them.
1) If left raised by porters e.g. after an x-ray
2) If raised by well meaning relatives as they leave the bedside. / Highlight to porters who are transporting a patient e.g. to x-ray about the need to inform ward staff that they are back and whether bedrails should be left raised.
Discuss with relatives whether bedrails are appropriate for the patient, using the new patient information leaflet.
3. New Post Fall Guidance
A patient was hoisted and moved in a way that may have caused more harm following a possible hip fracture. / Follow the new Post Falls Guidance, which is available from the Falls Prevention pages on the intranet.
Laminate the new Post Falls Guidance and display in a prominent place on the ward. Make all staff on your ward are aware of it.
4. Lying and Standing BPs
A patient displayed symptoms of postural hypotension and these were not recognised or acted upon by ward staff / medics (despite the fact that they were taking several medications causing postural hypotension). / Ensure that all patients have a lying and standing (or lying and sitting) blood pressure recorded on admission and after each fall.
If a postural drop is identified, inform the medics and discuss a review of culprit medications.
5. Medication reviews for ‘culprit’ medications
A patient did not have a review of their medicines on admission or after a fall. / Prompt medics to undertake a review of patients’ medications on admission and after a fall.
Pay particular attention to ‘medications that may increase the risk of falls’ (list available from the Falls Prevention pages on the intranet).
6. Osteoporosis risk assessment
A patient was admitted and discharged without their osteoporosis risks being reviewed. Bone health must be assessed on admission to reduce fracture risk. / Review patients’ osteoporosis risks on admission.
Raise patients’ osteoporosis risks to medics and ask if treatment would be appropriate.
If you need an update, you can access the osteoporosis e-video on the LEaD website.
SHFT Learning from SIRIs.Q1.2013-14