Improving neurological observations in inpatient falls

Introduction
Inpatient falls are a common patient safety incident associated with increased morbidity, mortality and prolonged hospital stay.1 Head injuries account for a significant proportion of fall-related harm, making timely neurological observations essential for early detection of deterioration.2 A baseline audit identified poor compliance with trust inpatient falls guidance, particularly omission of neurological observations when clinically indicated. This quality improvement project aimed to increase the frequency of neurological observation monitoring following inpatient falls on an acute medical ward by 30% and improve compliance with local falls policy by May 2025.

Method
A structured post-falls proforma was co-designed with ward nursing staff to address identified barriers to documentation. The proforma included a decision-making flowchart indicating when neurological observations were required, alongside dedicated sections for medical and nursing documentation and observations monitoring. Following implementation, supported by verbal reminders, retrospective review of inpatient falls between February and April 2025 was undertaken using Plan–Do–Study–Act (PDSA) methodology.3 Outcome measures included documented neurological observations, while process measures assessed proforma uptake and completion.

Results
Eighteen inpatient falls were reviewed. The proforma was completed in 28% (5/18) of cases. Overall, neurological observations were documented in 50% (9/18) of falls, increasing to 100% (5/5) when the proforma was used compared with 31% (4/13) without it, suggesting an association between proforma use and improved neurological documentation.

Uptake was limited, particularly during out-of-hours periods, reducing the intervention's overall impact. No clinically indicated neurological observations were missed. Key barriers included limited visibility of the proforma and documentation burden.

Conclusion
A structured post-fall proforma improved neurological observation documentation when used, demonstrating the value of embedded clinical prompts in supporting adherence to patient safety guidance and early detection of deterioration. Future PDSA cycles will focus on improving accessibility and proforma uptake and exploring electronic integration to support sustainable improvement.