Clinical Risk in Healthcare - Quality Management...

KING KHALID UNIVERSITY HOSPITAL

2012

Clinical Risk in Healthcare Risk Assessment Report

P A T I E N T S A F E T Y & R I S K M A N A G E M E N T U N I T

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CONTENTS

Introduction 3

Patient Fall Risk Assessment 4

Audit Questionnaire 5

Findings 6

General Comments 7

Recommendations 8

Suggested Measures to Prevent Pediatric Falls 8

Falls Prevention: A Required Organizational Practice 10

Pressure Ulcers Risk Assessment 11


Findings 12

Recommendations 14

Pressure Ulcer Prevention: A Required Organizational Practice 15

Suicide Risk Assessment 16


Findings 17

Recommendations 19

Suicide Prevention: A Required Organizational Practice 19

References 21

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Introduction

Clinical Risk Management focuses on “improving the quality and safety of healthcare services

by identifying the circumstances and opportunities that put patients at risk of harm and acting

to prevent or control those risks.” (Safety and Quality Council, 2005)

King Khalid University Hospital has identified, in accordance with evidence-based practices,

admitted patients who are at a degree of risk in certain circumstances. Examples of such risk

include;

Falls (Slip, trips and falls)

Pressure Ulcers

Surgical Procedures

Suicide

Venous thromboembolism (VTE) prophylaxis

Policies and procedures provide expected practices and directions to staff in addition to educational support. Required Organizational Practices have been promoted at KKUH to enhance patient safety and minimize risk. The Nursing Department at KKUH is forefront in implementing and monitoring clinical risk management. Staff have received education on when to conduct risk assessment using standardized tools and following standardized policies and procedures.

The scope of this audit is to determine the effectiveness of clinical risk assessment relating to:

Patient Falls (slips, trips & falls)

Pressure Ulcers

Suicide Prevention

The audit was conducted in a variety of clinical setting; Pediatrics, Surgical, Medicine, Mental

Health, Obstetrics/Gynecology, Long Stay and Intensive Care Unit. The data collection process

relied on documented evidence with additional clarification from staff on some occasions.

The audit was conducted between July and December 2012.

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PATIENT FALL RISK ASSESSMENT

Patient falls are a common and serious problem affecting the hospital inpatients. The scale of harm makes falls in hospitals an important concern for patients, their families and health care providers. In acute hospitals, the average reported rate is 5.6 falls per 1000 bed days.

Evidence-based research highlights the importance of conducting falls risk assessment on all admitted patients, following a significant change in status, following a fall and on a regularly scheduled basis.

Through the Occurrence Variance Reporting system, patient falls are captured and provide a hospital wide snap shot of the fall rate at KKUH.

Additional data is collected and monitored by Nursing Department through a Falls Log Sheet. Patient Falls is a hospital wide Outcome Indicator.

The Falls Risk Assessment or Morse Scale is a reliable and validated measure of fall risk. The

major advantages of this assessment is that it is research driven and interventions can be

standardized by the level of risk. Domains covered includes aspects relating to age, physical

capacity, cognitive ability, emotional status, history of previous falls, medications, etc.

Assessment is conducted on admission and thereafter, for example, should the patient undergo

any change such as following a fall, commencing a medication that may cause drowsiness, a

change in the dose of a medication, or following a surgical procedure. All field must be

completed and the outcome recorded on the risk assessment form.

2012 1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

TOTAL %

Patient Fall 22 14 17 24 77 3.2%

Patient Near Fall 1 1 2 1 5 0.2%

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Patients are assessed based on a numerical classification score and rated as Low, Medium or High Risk.

Audit Questionnaire

Question Yes No N/A Comments

Fall Risk Assessment on Admission

Risk identified Reassessed as per protocol Strategies put in place as appropriate

Documentation in Progress Notes

Patient education/instructions

Additional questions asked to nursing staff included:

1. Can you show me any easy reference bed side documentation, handover sheets, or signs that would tell you which of your patients are at risk of falls without you needing to read their case notes?

2. Can you show me any information or leaflet you would give to inpatients vulnerable to falling (or to their families/watcher)?

0

10

20

30

yes no

0

10

20

30

yes no

Risk Level: *High risk (>55) *Medium risk (30 - 55) * Low risk (0 - 25)

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Findings

Policies relating to Patient Falls can be found in the Hospital Wide Policy Manual under Patient Assessment and Re-assessment:

Additional guidelines can be located in the Departmental Manual of Nursing:

IPP MPS PATIENT FALL PREVENTION NUR-CLIIPP 004

Educational sessions are provided by nursing staff on a regular basis. Assessment of falls risk is a well established practice among all nurses at KKUH.

All Adult Patients are assessed on admission and on the majority of occasions when there is a change in health status. Depending on clinical area, re-assessment is performed each shift or

0% 20% 40% 60% 80% 100%

Falls Assessment O/A

Risk Identified

Re-assessed as per protocol

Documentation in Progress Notes

Strategies in place

Pt./Family Education

Falls Risk Assessment

N/A

No

Yes

Yes = Evidence sighted

No = No evidence

N/A = Not Applicable. For example patients in Long Stay areas had been admitted prior to implementation of Falls Risk Assessment and therefore this question was not applicable, however subsequent assessments have occurred.

4.13.2 Assessment for risk of fall

4.13.2.1 The nurses must assess all patients for fall risk as follows:

a) Use scale of risk to indicate the patient potential for fall. b) Identify the factor/s that may lead to fall. c) Inform the attending physician about the possible risk.

HWCIPP –004 - Patient Assessment and Re-assessment

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daily. Nurses conduct the assessment, record a numerical score and then indicate the outcome of the risk as being low, medium or high. Strategies are documented in the multidisciplinary progress notes which also includes whether or not the patient/family received education. Despite some patients not being assessed for fall risk, strategies were documented in the patients progress notes. This was most apparent in Pediatric areas. It was difficult, however, to find an easy reference or to quickly identify if a patient was a high fall risk. The Kardex was occasionally used to record this information.

It was noted, in regards to documentation, some instances when the risk assessment conflicted with the Activities of Daily Living (ADL) Assessment. For example it was documented that a patient was at risk of injury related to vertigo but this was overlooked during the Falls Risk Assessment process. On another occasion a patient had fallen at home. This was recorded in the history profile but not considered during the falls risk assessment. Several patients had been assessed pre-operatively but not post operatively.

ADL Assessment Falls Risk Assessment Comment

Patient drowsy and unable to maintain safe environment

Low Risk No inclusion criteria on Falls Risk Assessment Form.

Patient requires mobility assistance due to arthritis

Low Risk

Assistance required but no specific strategies provided.

Medium Risk Difficult to determine level of assistance require, e.g. 2 Person assist; walking aide, etc.

Risk of injury due to vertigo Low Risk

All Pediatric patients at KKUH are considered a high fall risk. Several clinical areas have both adult and pediatric patients, for example 33A, and whilst adult patients are assessed, pediatric patients are not. It was, however documented in some pediatric progress notes that watchers had been provided with education and information about falls prevention. According to staff Falls Prevention Brochures are available but were not available in some areas at the time the audit was conducted. Patient/family education was often not documented despite nursing staff stating that they do provide education to all admitted patients or their representative.

Documentation relating to fall risk did not always reflect a shared responsibility among the multidisciplinary team. According to staff, if a patient is identified as a high fall risk appropriate referrals are made.

Although mentioned in policy as a strategy to use to minimize fall, bed alarms or sensor mats

were not found to be in use at KKUH.

General Comments

Handrails are provided in all wet areas and corridors. Generally lighting was adequate. Patients

had access to call beds. Many wards were congested and did not promote an environment that

aimed to prevent falls. For example nurse work trolleys were found in the doorway or corridors

of some wards. Due to inadequate storage space a broken bed was placed where it impeded

thoroughfare to a toilet – a patient had to carefully negotiate to access the toilet. The spaces

between beds was found to be restricted which is complicated further by watchers sleeping on

Patient fall alarms may be used when the patient is in bed or sitting in a chair. IPP MPS PATIENT FALL PREVENTION NUR-CLIIPP 004

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the floor. One bathroom did not have a drain and the potential for water to collect on the floor

high thus contributing to an unsafe environment. Small rubbish bins were another obstacle

noted that could contribute to a patient fall.

Recommendations

1. When a fall risk assessment is introduced, it needs to be supported by education for all staff and intermittent reviews to ensure it is used appropriately and consistently.

2. Currently assessment, education and falls prevention are a nursing responsibility. It is important that falls prevention programs have a multidisciplinary approach. Falls prevention programs need to include a more active role by Physiotherapists. Patients identified with ongoing balance and mobility problems need to be referred to a falls prevention exercise program. This should include liaison with the Physiotherapist who can assess balance, mobility and strength. Evidence identifies the relevance of Vitamin D and calcium and good nutrition. The Physician and Clinical Dietitian play important roles in these areas.

3. Ensure documentation of episodes of patient education using the Multidisciplinary Patient and Family Education Form and/or Multidisciplinary Progress Notes. Documentation should also evaluate the effectiveness of strategies implemented and learning outcomes.

4. Patients have an important role to play in falls prevention and education is a key component. Information, written and verbal, need to accommodate both adults and children. Ensure educational materials are readily available in all clinical areas – nominate responsible person(s). The brochure provided to patients “Preventing Patient Falls”, printed in both English and Arabic, is photocopied in black and white and not a good quality.

5. Several pediatric falls assessment tools are available and could be considered for adaptation at KKUH, for example the Little Schmidy Falls Risk Assessment Tool, CHAMPS, Humpty Dumpty Falls Assessment and the I‟m Safe.

6. Develop methods to alert other staff that a patient is a high fall risk. A new standardized wristband system is being implemented throughout KKUH. One of the future plans it to use a yellow lock on the wristband to help identify patients who are at risk of falling. Evidence does suggest however that such strategies do not impact on falls reduction. Some children‟s hospitals have found the use of non-slip colored socks worn by the pediatric patient as useful. Signage at the patient‟s bedside can also be helpful and most importantly is consistent effective communication at endorsements and at transition points.

7. Review ward layouts and remove unnecessary items such as nurse work trolleys. Replace small rubbish bins with one bin for general waste and provide small rubbish bags that adhere to the patient‟s bedside table or over way table.

8. Assess individual needs of each patient. Bed rails which are also a form of restraint, are often used as a measure in falls prevention, however some evidence states to the contrary and that injuries resulting from the use of restraints can be more serious.

9. Some Fall Risk Assessment forms have been photocopies so that only the assessment is available. The strategies and recommendations have inadvertently been omitted.

http://www.rch.org.au/uploadedFiles/Main/Content/rchcpg/Little_Schmidy_Falls_Risk_Assessment.pdf

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Suggested Measures to Prevent Pediatric Falls

• Complete fall risk screen; Reassess if changes in physiologic/ motor/ sensory/cognitive status.

• Identify at-risk patients with sticker, ID band, symbol. • Adhere to institutional safety protocols: – Orient child/parent to room/bed. – Use assistive devices properly. – Maintain surveillance of floors and surfaces for fluids/objects. – Assist with ambulation as needed. – Place call light, telephone, and personal articles within reach. – Use cribs, high chairs, and infant seats properly. – Use side rails and protective device (crib hood, gait belt, etc.) appropriately. – Keep beds/cribs/stretchers in the lowest, locked position. – Use wheel locks when indicated. – Keep environment uncluttered and free of obstacles. – Provide adequate lighting. Individualize standardized care plan. Wear non-slip footwear when up. Offer patient assistance to the bathroom/place commode at bedside. Evaluate medication administration times. Frequent monitoring/ keep door open. Caregiver/Watcher at bedside/Room assignment that provides more direct observation. Assess parents‟/primary caregivers‟ ability to set appropriate behavioral/ activity limits. Education of parents/primary caregivers regarding: – Fall risk factors. – Appropriate transfer/ ambulation needs. – Appropriate use of side rails.

(PEDIATRIC NURSING/July-August 2009/Vol. 35/No. 4 page 231)

Overview of Recommendations

Hospital Wide policy available × Falls prevention program in place √ Falls Risk assessment on admission: ADULT √ Falls Risk assessment on admission: PEDIA × Multidisciplinary team approach to risk management for patient falls

×

Risk documented √ Strategies put in place √ Patient/family education × Easy access to alert other staff of fall risk ×

Improvement

required

Partial compliance Compliance

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FALLS PREVENTION: A REQUIRED ORGANISATIONAL PRACTICE.

Accreditation Canada has identified a Falls Prevention strategy as a Required Organizational Practice (ROP). Within the program of Accreditation Canada, a Required Organizational Practice is defined as an essential practice that organizations must have in place to enhance patient/client safety and minimize risk. The goal of this Required Organizational Practice is to reduce the risk of injuries resulting from falls. There are a number of tests for compliance, which include: • The team has implemented a fall prevention strategy. • The strategy identifies the population(s) at risk for falls. • The strategy addresses the specific needs of the population at risk for falls. • The team evaluates the fall prevention strategy on an ongoing basis to identify trends, causes and degree of injury. • The team uses the evaluation information to make improvements to its fall prevention strategy.

Accreditation Canada has identified Falls Prevention as one of the seven areas of Required Organizational Practices (ROPs). An ROP is defined as an essential practice that organizations must have in place to enhance patient/client safety and minimize risk.

If you think that your patient is at risk of falls,

then they probably are.

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PRESSURE ULCER RISK ASSESSMENT

Pressure Ulcers are highly preventable and evidence asserts that timely assessment is the best approach to prevention and management. The effectiveness of a pressure injury prevention program depends on the combined effects of the risk assessment scale, the preventative measures used and the compliance with policies and protocols. The purpose of a risk assessment tool is to identify individuals „at risk‟ of developing a pressure ulcer. All patients admitted to KKUH are assessed for risk of developing pressure ulcers. The Braden Scale is the tool used at KKUH along with the Braden Q Scale to assess pediatric patients. This risk assessment tool evaluates six indicators; sensory perception, moisture, activity, mobility, nutrition, and friction or shear. The use of such assessment tools aims to prevent and effectively manage pressure ulcer formation. The Braden risk assessment tools utilize a numerical scoring system to weigh the severity of risk into the categories:

Pressure related injuries are reported through the Occurrence Variance Reporting system and

are classified according to the incident details. In acute hospitals, the average reported rate of

pressure ulcer development is 6.9 per 1000 bed days.

2012 1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

TOTAL %

Skin Peel 24 10 7 6 47 1.9%

Pressure Ulcer 3 3 4 5 15 0.6%

Blister 12 4 0 1 17 0.7%

Risk Level: 9 or below Very High risk 10 -12 High Risk 13-14 Moderate Risk 15-18 mild Risk

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Audit Questionnaire

Findings

There is a policy, Maintenance of Skin Integrity NURS-CLI 005, in the Department of Nursing

Manual however this needs to be revised as it refers to the Norton Scale. Nursing assessment

emphasizes the importance of checking skin integument. There is a Patient Turning Chart used

to indicate when a patient requires two hourly repositioning.

All patients, both adults and pediatric patients, are assessed on admission for the risk of

developing a pressure ulcer. Nursing staff record the results based on a numerical value and

further documentation occurs in the Multidisciplinary progress notes. An algorithm on the

back of the assessment form provides guidelines for nursing staff.


Braden Scale on Admission Risk identified Reassessed as per protocol Strategies in place as appropriate Documentation in Progress Notes

Patient education/instructions

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There was documented evidence showing the involvement of a multidisciplinary team approach to the management of a patient with a pressure ulcer - Plastics, Wound Management Team, Pain Clinic and Clinical Dietician were involved in the planning of care. When trying to establish specific information about a pressure ulcer, for example the size, type of exudate, dressing regime, this was recorded in the Multidisciplinary Progress notes. There was no specific form used that could be easily located in the patient file. Re-assessment occurs either on a per shift basis or daily. There was evidence that risk assessment for pressure ulcers is a well established practice at KKUH.

Patient/family education and instruction are important aspects to assisting in minimizing pressure ulcer formation. Ensure documentation is completed to reflect this communication has occurred.

0% 20% 40% 60% 80% 100% 120%

Assessment on Admission

Risk Identified

Reassessment as per protocol

Strategies in place

Patient Education/instruction

Braden Scale (Adult)

N/A no yes


No = No evidence

N/A = Not Applicable. For example patients in Long Stay areas had been admitted prior to implementation of Braden Risk Assessment and therefore this question was not applicable, however subsequent assessments have occurred.

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Recommendations

1. Revise and update Maintanence of Skin Integrity policies to be in accordance with practices at KKUH.

2. Consider the role manual handling plays to maintain skin integrity. Exposure to shear and friction should be reduced by employing correct manual hadling techniques. There is a device called a Slide Sheet than can be used to reposition patients thus reducing unnecessary friction.

3. Annual staff training and education on correct manual handling techniques. 4. Ensure strategies are docummented that relate to pressure relieving devices relating to

pieces of equipment such as plaster casts, pulse oximeters, oxygen masks, and CPAP masks.

5. When reporting pressure injuries via the Occurrence Reporting System, refer to the Staging classification system where possible.


Polices and processes in place √

Pressure Injury prevention program in place

√

Risk Assessment for Pressure Ulcers O/A √ Multidisciplinary Team approach √ Risk documented √ Strategies put in place √

Patient/family education ×

Improvement

required


0% 20% 40% 60% 80% 100% 120%

Assessment on Admission

Risk Identified

Reassessment as per protocol

Strategies in place

Patient Education/instruction

Braden Q Scale (Pedia)

no

yes


No = No evidence

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Pressure Ulcer Prevention: A Required Organizational Practice

Accreditation Canada states that the organization assesses each clients risk for developing a

pressure ulcer and implements intervention to prevent pressure ulcer development.

Guidelines

Standardized research-based pressure ulcer prevention and treatment protocols can

substantially reduce prevalence of pressure ulcers. Preventing pressure ulcers improve client

quality of life caregiver morale, and is indicative of higher quality care and services. In

addition, preventing pressure ulcers reduce health services costs.

Test for Compliance

The organization conducts an initial pressure ulcer risk assessment at admission using a

standardized risk assessment tool

The organization reassesses each client for risk of developing pressure ulcers at regular

intervals

The organization implements documented protocols and procedures to prevent the

development of a pressure ulcer which includes interventions to prevent skin

breakdown, reduce pressure, reposition, manage moisture, maximize nutrition and

enhance mobility and activity,

The organization educates staff on the risk factors and strategies for the prevention of

pressure ulcers.

The organization monitors it success in preventing the development of pressure ulcers

and makes improvements in its prevention strategies and processes.

Accreditation Canada has identified Pressure Ulcer

Prevention as one of the seven areas of Required

Organizational Practices (ROPs).

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SUICIDE PREVENTION RISK ASSESSMENT

Suicide risk assessment has been identified as a fundamental safety issue among health care organizations. A lack of information on and documentation of suicide risk has been identified as a common issue in reviews of cases where persons have died by suicide in inpatient mental health settings. Suicide risk assessment is a multifaceted process for learning about a person, recognizing and addressing his or her needs and stressors, and working with him or her to mobilize strengths and supports. Suicide is defined as an intentional, self-inflicted act that results in death. Risk factors for suicide include mental disorder (such as depression, personality disorder, alcohol dependence, or schizophrenia), and some physical illnesses, such as neurological disorders, cancer, and HIV infection. (W.H.O.) All Mental Health patients entering King Khalid University Hospital should have a risk

assessment conducted to determine suicidal ideations or tendencies.

Audit Questionnaire


Policy/Procedure available Patient assessed on admission Suicide Risk Assessment Tool available

Staff have received training on Suicide Prevention Management.

0% 20% 40% 60% 80% 100%120%

Policy/Procedure available

Patient assessed on admission

Risk Assessment for Suicide Tool available


No

Yes

Audit Results

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Findings

The following policies contain processes and procedures relating to suicide risk assessment at

KKUH:

Further policy information can be found in:

An initial assessment is conducted by nursing staff on admission through Emergency

Department following routine procedures. This includes a thorough physical search to ensure

the patient has no concealed item that could be used to harm themselves. A psychiatrist

4.3 Patient assessment will be done as following:

4.3.2 Psychological assessment: By admitting physician and nursing staff

4.3.2.1 All patients will need to be screened for psychological needs.

4.3.2.2 Screening may require further comprehensive assessment based on

established criteria.

4.3.2.3 Patients requiring further assessment has to be identified during daily

rounds.

a) Findings must be documented in the patient medical record

b) If further assessment is required, a psychiatry consultation has to be

performed

4.13 Nursing responsibilities:

4.13.1.Patient Assessment

4.13.1.1 The nurse assigned at the time of admission must

document comprehensive written nursing assessment within

eight (8) hours of admission. This assessment must include:

a) Patient psychological condition

b) History of patient and main complaint.

HWCPP-004 Patient Assessment and Re-Assessment

PSY IPP-002 Assessment for Suicidality

PSYIPP-013 Suicide Levels Of Observation

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assesses the patient and documents the findings in the multidisciplinary progress notes along

with specific orders. There is an assigned padded room with close circuit monitoring. Usually

one nurse is assigned to special the patient.

On transfer to the psychiatric unit, additional assessment and documentation is conducted by

nursing staff who also do a physical check on the patient and their belongings. Psychiatric

Department have developed a Psychiatric Assessment Form which includes a field for suicide

risk. During the audit it was noted this field was often left blank. This is currently an

unapproved form.

The psychiatrist is responsible for documenting in the Physicians Orders any suicide

precautions. While waiting for the review, it is the responsibility of nursing staff to implement

suicide prevention measures. Suicide orders are reviewed every 24 hours by the

Multidisciplinary team. The multidisciplinary team also includes psychotherapist and social

workers.

When a patient is identified as a suicide risk, an Eight Hour Suicide Observation Checklist is

commenced. Fields include: one on one observation Nurse; Observation every 15 minutes;

Observation every 30 minutes. In some instances the Client is requested to sign the checklist.

This checklist is used over a 24 hour period.

Nursing staff conduct regular proactive inspections that include environmental and physical

checks of the patient to detect hazardous material. This inspection routinely occurs before and

after visiting hours as visitors may inadvertently give the patient a lighter, knife, spray, glass

item, belt, hairpins, scissors, safety pins, eye glasses, etc. These items are removed to protect the

patient and others from possible harm. They are stored securely and identified so they can be

returned to the family when they visits next. Explanations are provided to the patient and

visitors so they understand the reason behind such actions. Staff document their findings on an

environmental checklist form.

Many of the patients are long term, and visitors are requested to provide feedback on a weekly

basis to gauge their perception on patient progress. A Visitation Feedback sheet, in Arabic

allows for the relative to record their assessments in their own words. This is kept in the

patients file. This provides valuable fed back that can be related to risk management.

Nursing staff document in the multidisciplinary progress notes each shift and as required.

Nursing entries reflect a daily physical assessment of the patient to detect any evidence of

injuries and according to staff this is done each shift to ensure the patient is not inflicting self

harm.

Rooms are monitored via surveillance cameras.

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Recommendations:

1. Ensure staff in Emergency and Psychiatric Department receive training and education on preventative suicide management and risk assessment.

2. There are no policies available for staff in Emergency Department relating to suicide prevention except in cases of when to report such an event to Police or Ministry of Health.

3. Provide a standardized risk assessment tools that will help determine the level of risk/interventions required.

4. Revise form (Psychiatric ADL) to include yes/no or not applicable rather than leave blank, especially in relation to suicide assessment.

5. The nurses‟ station is open and accessible to patients. Consider this being a restricted area.

Examples of Suicide Risk Assessment Tools

Beck Hopelessness Scale . Beck Scale for Suicide Ideation (BSS ®) . Columbia-Suicide Severity Rating Scale Modified Scale for Suicide Ideation Nurses‟ Global Assessment of Suicide Risk Reasons for Living Inventory SAD PERSONS and SAD PERSONAS Scales Scale for Impact of Suicidality – Management, Assessment and Planning of Care Suicidal Behaviors Questionnaire Suicide Intent Scale Suicide Probability Scale TASR

Suicide Prevention: A Required Organizational Practice.

Accreditation Canada requires regular assessment of suicide risk of all persons in mental health service settings as a “Required Organizational Practice” (ROP). This is now a standard requirement for addressing the immediate and ongoing safety needs of persons identified as being at risk, and appropriately documenting risks and interventions in the person‟s health record (Accreditation Canada, 2011). While accreditation and quality monitoring organizations mandate the use of suicide risk assessment, it is important to recognize that this process should not occur simply to mitigate liability in response to such mandates (Lyons, Price, Embling, Smith, 2000). Instead, suicide risk assessment should be viewed as an integral part of a holistic therapeutic process that creates an opportunity for discussion between the person and care provider, and his or her family and other supports.

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Improvement

required


Policy/Procedure available √

Patient assessed on admission √ Risk Assessment for Suicide Tool available ×


×

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REFERENCES

Falls Pilot Audit Report February 2012. ©Royal College of Physicians 2012

http://www.suicide risk management - Diagnosis - Step-by-step - Best Practice - English.mht http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

JBI Best Practices, Falls Prevention. www.joannebriggs

Pressure Injury Management and Guidelines SA Health.

Required Organizational Practices 2012. Accreditation Canada.

Suicide Risk Assessment Guide: A Resource for Health Care Organizations. (2011). The Ontario Hospital Association & The Canadian Patient Safety Institute. Canada.

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