Falls Risk Assessment Documentation Audit

This project audits whether falls risk assessment and prevention documentation is completed reliably and meaningfully. It reviews identification of falls risk, falls history, mobility, gait and balance, cognition and delirium, vision, footwear and environment, continence, postural symptoms and lying-standing blood pressure, medication-related falls risk, bone health, individualised prevention planning, escalation and therapy or MDT referral, communication with the person and their carers, handover updates and post-fall review.

• Ward nursing teams, ward leaders and patient safety teams
• Acute medicine, geriatric medicine, frailty and orthogeriatric teams
• Physiotherapists, occupational therapists and rehabilitation teams
• Pharmacists and medicines optimisation teams
• Care home clinical leads and community teams where locally relevant
• QI leads, governance teams and educators

• Measure whether falls risk is identified and assessed according to local policy
• Assess coverage of the relevant multifactorial falls-risk factors
• Review whether prevention plans are individualised and interventions documented
• Identify variation in escalation, therapy referral, communication and post-fall review
• Generate governance-ready and ARCP-ready evidence

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised biodata (age band, recorded sex/gender, care setting, assessment context)
• Clinical area / location and optional specialty / service
• Fourteen falls risk assessment documentation criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports, but does not replace, clinical judgement. Follow local falls policy, multidisciplinary assessment and specialist advice.
• Risk-score thresholds, timing expectations and required interventions remain locally configurable and are not national standards.
• Use anonymous case identifiers only — never patient-identifiable information.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Quality ImprovementAvoiding Common PDSA Pitfalls: A Guide for Effective QIThis guide addresses frequent errors in planning, doing, studying, and acting (PDSA) cycles, offering practical advice to enhance the effectiveness of your Quality Improvement initiatives within the NHS.
• Patient SafetyLearning from Near Misses: Enhancing Patient Safety in the NHSThis guide provides practical strategies for NHS clinicians and teams to proactively identify, report, and learn from near misses, helping to prevent adverse events and improve patient safety.
• Patient SafetyDesigning Safer Clinical Processes: A Guide for Healthcare TeamsThis guide outlines practical approaches to designing safer clinical processes within the NHS, incorporating principles of human factors, error prevention, and system resilience. It aims to equip healthcare teams with the knowledge to identify risks and implement robust safety measures.
• Patient SafetyAchieving Reliability in Healthcare Systems: A Practical GuideThis guide explores the concept of reliability in healthcare, providing practical strategies for NHS teams to design and implement robust processes that reduce errors and improve patient safety.