During a serious fall, feedback regarding what transpired is essential in terms of helping the care team learn how it happened. Ideally, revisiting the circumstances of the fall should be done with the patient, the patient’s family as well as the multidisciplinary team and health services in order to mitigate the problem. This forms the basis of learning about risk management.
A fall is similar to any other unwanted event: it’s something you have to analyze. For this, we can use analysis charts like the alarm charts consisting of seven families of causes. The pathology of the patients and their risk of falling is one of the points that constitutes it, but not the only one. Indeed, six other families of causes can also be associated with the elements of circumstances around the fall, for example, on account of a lack of staff.
In addition to this dimension, we will also look for why this fall has happened, the way it has been managed, and what mitigators the team put in place to limit its gravity.
These two components form the core focus of the analysis by looking at the causes of the fall, then looking at the consequences in order to measure the effectiveness of the team.
Many factors, many people
This analysis must be multidisciplinary because one does not fall on account of a single factor, nor is only one person in charge of the patient. Indeed, it is not the last person to have seen the patient who must be responsible for this management of the fall, it is the whole team that must get involved in this analysis.
Understand as a team
It is often believed that good solutions are official solutions which we will compile in the files over the course of three months. But in reality, this is a very difficult thing to achieve. The actual solution to being effective in sharing all information is to be explicit, to use easily understandable language that is clear to everyone. This is probably the best way to share a posteriori information within the team. For example, we can try to meet for 10 minutes a month to analyze a problematic situation.
The lessons that are drawn from a fall are the most important thing because when patients fall, their fear of falling again increases. And the more the falls are repeated, the more the patients will restrict their own movements. This spontaneous self-restriction will result in a second-level risk where the patients start to lose their autonomy, resulting in additional problems.