Table 1

First PDSA cycle (July 2021)

	What	Rationale	Who
Plan	To educate Staffs on proper use of paediatric fall assessment form (Humpty Dumpty fall chart) and fall risk categorisation and fall prevention advice after risk assessment	Root cause analysis highlighted that there was no uniformity in the use of fall risk assessment form, documentation and the fall prevention advice given.	QI team
Do	Humpty dumpty fall chart were printed out and staffs were educated to use it in a uniform way and to document the risk category in patient file One hour presentation was given to the ward staffs and paediatric residents covering fall prevention advices to be given to the patient and their attendants		QI team Ward nurses Residents
Study	The fall incident rate for July was studied. There was no decline in the fall incidence rate Patient’s charts were reviewed Lack of attention to patients at high risk of fall was identified as one of the cause of inpatient falls in our ward		QI team
Act	Called a meeting with all the QI members Reviewed all the fall incidents form Discussed about interventions which can help in providing special/extra attention to high risk of fall patients.		QI team

QI, quality improvement.