POST-FALL HUDDLE

INFORMATION FOR CLINICIANS & HEALTH PROFESSIONALS

Inpatient falls are one of the most common

patient safety incidents and can result in
serious harm to patients, including permanent
physical disability and occasionally death.

Post-fall huddles are used in inpatient settings

of care to determine the cause of the fall, and
intervene appropriately. It aims to ensure risks
are recognised, communicated and managed
in achieving desired health outcomes,
enhancing service delivery and preventing
further harm to patients.

Benefits of a Post-Fall Huddle

A post-fall huddle is a “group think tank”
Post-fall huddles:
following a fall to try and prevent another fall.
• Provide a structured, personalised
Note: The Clinical Excellence Commission
intervention to reduce the risk of a repeat
post-fall process must still occur.
fall
• Improve staff compliance with safety
• Where possible the huddle should occur
protocols
with the patient and or family present
• Develop a culture of patient safety that
• Where possible the huddle should occur in
treats falls and near miss falls very
the environment where the fall occurred
seriously
• Where possible the huddle should occur as
• Provide a comfortable way for staff to offer
soon after the incident as practical.
an apology to the patient
• Increase situational awareness, so staff can
anticipate situations that may lead to a fall.

Post Fall Huddle - Information for Clinicians and Health Professionals

Released October 2017, © Clinical Excellence Commission. SHPN (CEC) 170589

About the NSW Falls Prevention Program

The CEC’s Falls Prevention program aims to reduce the incidence and
severity of falls among older people and reduce the social,
psychological and economic impact of falls on individuals, families and
the community.
For further information, please visit http://www.cec.health.nsw.gov.au
 EXAMPLE POST-FALL HUDDLE AGENDA

• The registered nurse/team leader welcomes people to the huddle and explains the purpose

Welcome

• If possible, have the patient explain what happened in their own words.
What • The clinician who was present, or who found the patient, describes the fall and environment.
happened
(root cause)

• Will assist in identifying prevention strategies to reduce the risk of another fall.
What
contributed

• Identify or clarify fall risk factors.

Risk factors
identified

• Consider medication review, intentional rounding, assistance with mobility and aids, toileting needs, fall
equipment (e.g. bed alarm).
What will • Consider delirium, infection, sepsis or low BP.
reduce the
risk

• Identify who is responsible to ensure the actions are followed up e.g. update fall risk screen. Follow Post-
Fall Management guide, update the patient care plan, communicate the incident to the family/carer,
document the post fall huddle, make referrals etc.
What do we • Communicate fall and interventions at clinical handover.
need to do

• Identify any lessons learnt.

• Communicate lessons learnt and share at team meetings.
What lessons
learned