Reply To: Post-Fall Process

  • Kimberly DiGerolamo

    November 4, 2021 at 12:40 pm

    What is your post-fall process? 
    Hi, At CHOP we do the following: 
    We have a tier 1 and tier 2 approach for all events of harm. So after a fall event we would have a quick huddle (our tier 1) where we would meet with the bedside nurse, charge nurse, MD and patient/caregiver to discuss what happened and make sure we are putting interventions in place so the event does not occur again for that patient and to identify anything that might put other patients on the unit at risk (for ex. environmental reason for fall). 
    Our unit-based safety and quality specialist would then schedule a tier 2 review which would include the unit fall reps, hospital-wide fall prevention leads, and members of our leadership team to come a discuss the event in more detail. This usually happens a couple days later after a review of the chart to look at documentation of fall prevention practices and interview of those who have cared for the patient over several shifts to identify any additional risk factors, concerns or gaps. 

    In terms of documentation, after the fall event, an incident report is filed, the nurse re-scores the patient’s fall risk, and we have developed a note template in epic that describes the fall event. 

    Kimberly DiGerolamo,DNP, RN, PCNS-BC, CPHON, CPN
    Clinical Nurse Specialist Division of Oncology
    Children’s Hospital of Philadelphia
    Original Message:
    Sent: 11-04-2021 11:25 AM
    From: Sherry Johnson
    Subject: Post-Fall Process

    We enter falls in our event reporting system, perform fall huddles and complete the follow-up for falls in the event reports.
    Enclosed is the nursing and institutional policy.

    Sherry Johnson, CPON,MSN
    West Memphis, AR
    United States

    Original Message:
    Sent: 11-04-2021 10:26 AM
    From: Angie Blackwell
    Subject: Post-Fall Process

    Hi Chris!

    We are just getting ready to roll out post fall huddle/debriefings using the attached form. The huddle will take place after a fall and be entered into REDcap (electronic database).

    The fall is also documented in the EHR and a safety report is completed.



    Angie Blackwell, MSN, RN, ACCNS-P, CPON
    Clinical Nurse Specialist




    1201 W. La Veta   |  Orange, CA 92868




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    Original Message:
    Sent: 11/4/2021 10:23:00 AM
    From: Chris Donaghey
    Subject: Post-Fall Process

    APHON team,

    As we know, preventing falls in pediatric patients is challenging for many factors.

    Many of our units have standardized assessment tools, but even they don’t always capture the variability and urgency of risks with certain patients.

    My question:

    What is your post-fall process?

    If a patient falls on your unit, other than documenting the event in the electronic health record, what occurs?

    Who is involved in the process?

    I’m curious about benchmarking as the process has the potential to be burdensome without much value added.


    Chris Donaghey, MSN, RN, PCNS-BC, CPN, CPHON
    Clinical Nurse Specialist – Center for Pediatric Cancer and Blood Disorders
    Riley Hospital for Children at IU Health
    Indianapolis, IN