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Incident Report |
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| Particulars of incident: Fall of a patient in confined bathroom | |||
| Date: 10 August, 2018 | Time: 1627 | Location: | |
| Type of incident (please circle below): | |||
| Injury Illness Environmental Notifiable event Other: | |||
| Reported by: | Phone: | ||
| Role in the event: Assessor | Email: | ||
| The injured person: | |||
| Name: Abraham Johnson | Address:795 E Dragram, Tucson, AZ | ||
| Age: 67 | Phone:752-2843 | ||
| Witness(s): | |||
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Name: Margaret Turner Name: Robbie Adams Name: William Tate |
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| Describe the incident: (space overleaf for diagram if needed) | |||
| The incident involved Johnson falling in the shower. Having made some encouraging progress, it was determined that Johnson was able to use the bathroom unaided. Therefore, he was not provided with any walking aids. Moreover, none of the nurses who were assigned to him were with him at the time of the fall. On his return to his room, Johnson fell and suffered a hip fracture. | |||
| Describe any illness or injury: What part of the body is affected and how? | |||
| Johnson suffered a number of injuries. Though not life-threatening, the injuries underscore the importance of caution and implementing fall prevention strategies. His hip is the main part of his body that suffered injury. The hip injury took the form of a fracture. It is believed that the fracture resulted from the fact that Johnson fell from a great height and was unable to break his fall. | |||
| Describe any property damage: What damage was caused and how? | |||
| No hospital property suffered significant damage. However, a preliminary assessment revealed that the bathroom basin developed cracks. The cracks occurred as Johnson was attempting to break his fall. | |||
| Analysis: What do you think caused or contributed to the incident? | |||
| There are a number of factors that are to blame for Johnson’s fall. That he was determined to be capable of using the bathroom without help is one of these factors. Johnson was not adequately prepared for the challenges of autonomy. The attending nurses should have been with him as he used the bathroom. The lack of grip on the bathroom floor is another factor that led to the incident. An observation of the bathroom revealed that it was slippery and that given Johnson’s age and condition, it was only a question of time before the fall occurred. Another issue which could be responsible for the fall is that the bathroom was confined. Johnson lacked enough room to navigate and prevent the fall from occurring. Failure by the attending nurse to provide Johnson with walking aids is another issue that can be linked to the fall. Johnson fell because he lacked the aids that would have enhanced his stability. | |||
| Prevention: What action has been taken to prevent a reoccurrence? | |||
| Johnson’s fall prompted the hospital to take measures to ensure that no other patient suffers a fall. Requiring that all elderly patients with conditions which impair mobility be accompanied by a nurse when using the bathroom is one of the measures. It is hoped that as nurses work closely with the patients, the number and severity of the falls will be reduced. Another preventive measure that has been implemented involves providing patients with walking aids. These aids have been shown to play a critical role in enhancing the stability of elderly patients. As part of its efforts to rid the environment of all fall hazards, the hospital has instructed all its practitioners to ensure that all floors are clear of such items as cords. It is understood that these items could cause patients to trip and fall. In recognition of the need to promote patient safety, the hospital has also introduced a new protocol for transferring patients from their beds to the wheelchair. Now, it is required that the transfer should be carefully coordinated and that the brakes of the wheelchair should be engaged. Moreover, the hospital stipulates that before leaving the patient’s room, the attending practitioner should ensure that the bed is at the lowest level. Patients are also to be provided with aids to facilitate moving from the bed. The measures that the hospital has instituted are inspired by the need to secure patients against falls. The full implementation of the measures will help to create an environment of safety and wellbeing. | |||
| Have all preventative actions been reviewed by the Event Management Committee and implemented? Yes No | |||
| <Event Management Committee> Signature: | Date completed: | ||
| Treatment: | |||
| A & E Hospital: No emergency treatment was found necessary. | Doctor: Nicholas Gates | ||
| Type of treatment provided: Pain killers administered. Patient underwent surgery to fix hip fracture. | |||
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