A Self-Assessment Guide for Health Care Organizations - IFC

Standard PS.6 [Falls prevention]
The organization develops an approach to reduce the risk of patient harm resulting from falls.
Intent of PS.6
Falls account for a significant portion of injuries in hospitalized patients. The organization should evaluate patients’ risk of falls and take
action to reduce this risk and to reduce the risk of injury should a fall occur. The evaluation could include fall history, medications and alcohol
consumption review, gait and balance screening, and walking aids used by the patient.
The organization establishes and implements a fall-risk reduction/prevention program. This is based on appropriate policies and/or procedures,
and on physical modifications to the facilities (e.g. fitting of hand-rails, non-slip floor covering etc).
Measurable Element Look for Score Observations
What is required
1) A collaborative process
is used to develop policies
and/or procedures aimed
at reducing the risk of
patient harm resulting
from falls in the
organization.
How is this element
assessed
Physicians, nurses and other health
care workers work together to
write and implement policies and
procedures to reduce the risk of
falls. Review minutes of meetings
and talk with staff members
regarding their involvement.
0 5 10 Why did you give this score
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2) The organization
implements a process for
the initial assessment of
patients for risk of falls.
This includes reassessment
of patients when indicated
by a change in condition,
medications, etc.
Review policies and procedures,
e.g. fall risk assessment and
protocol. Ask staff members
regarding how they assess patients
for risk of falls. Review medical
records to determine if a fall
assessment has been completed,
and re-assessments done as
indicated.
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3) Measures are
implemented to reduce fall
risk for those assessed to
be at risk.
Observe the use of fall-prevention
measures during safety rounds. Ask
staff regarding their knowledge of
the fall risk protocol.
Observe physical measures taken,
e.g. handrails, non-slip floor
surfaces etc.
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62 IFC Self-Assessment Guide for Health Care Organizations