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1. Goal 6
Reduce the Risk of
Patient Harm
Resulting from Falls

2. Definition
• A fall is an incident in which an adult or a child
unexpectedly falls down, unassisted or uncontrolled, from
a higher position to a lower position, with or without
injuries and which may or may not be related to physical
or mental pathology.
Fall
• sudden loss of balance that does not result in a fall or
other injury .
• This can include a person who slips, stumbles, or trips but
is able to regain control prior to falling.
Near Fall
• occurs when a patient is found on the floor and neither
the patient nor anyone else knows how he or she got
there .
un-witnessed fall

3. All in-patients will be
assessed for the risk of
fall upon admission.

4. Most Causing to Falls
• Loss of consciousness.
• Orthopedic disorders.
• Hypoglycemia.
• Anemia, Vision
• Hypotension.
• Drugs action.
• Post operative (sedation).
• Aging and sleeping habits
• Paralysis, TIA, CVA
Individual
• Unsafe higher position.
• Beds side rails.
• unlocked wheelchair.
• Water in the floor.
• Wire connections.
• Steps or stairs.
• Walker.
• Interfering Clothes
Environmental

5. Patient Fall Injury Levels
None:
• No injury.
Minor:
• minor injury
with abrasion
or bruise
treated by
dressing, limb
elevation,
topical
medication.
Moderate:
• injury lead to
Suturing or
limping treated
by bandage,
splinting,
muscle or joint
strain.
Major:
• which leads for
casting, skin
traction and
surgery, may
need
neurological
and vascular
attention.
Death:
• the patient died
as a result of
serious injury.
UTD:
• unable to
determine from
the
documentation
.

6. Fall assessment
All in-patients will be assessed for the risk of fall upon admission.
•post operative.
•following procedural sedation.
•after administer medication.
•after blood transfusion.
•transferring patients between 2 units.
•after recording incident of fall.
•any changing in ambulatory status or elimination status,
Reassessment is indicated for all of the following conditions:
•Hendrich 11 Fall risk for Adults.
•Humpty Dumpty Scale for Pediatrics.
•The Morse Fall Scale
Applying Risk Fall procedure for patients
Standard fall precaution shall be implemented for all patients.
Reporting and documenting any fall occurrence.
All Falls patients should be classified according to level of Injury

7. Post Fall Protocol of Care
First Aid.
Ensure that patient
is safe from further
danger .
ask for help.
don’t reposition the
patient until the
patient is ready to
do so.
move the patient
safely with
attention to moving
and handling.
complete the post
fall assessment
Form
Reporting.
Patient and Family
Education.

8. Standard Fall Precaution for Low-Risk Patients
1
Orient the
surrounding
environment.
2
Provide
Medication
Information.
3
Instruct patient
to call for
assistance.
4
Instruct to use
the rubber –
soled shoes or
non – slip
footwear to
prevent
slipping.
5
Secure call bell,
phone, bed
table.
6
Ensure the
clothes are not
interfere with
the patient
mobility.
7
Maintain the
bed in the
lowest position
and ensure bed
and
wheelchairs
are looked.
8
Put side rails.
9
Conduct
regular
environmental
rounds in all
areas
surrounding
the patients to
decrease the
risk of falls.
10
Keep
bathroom light
on and the
floor dry.

9. Standard Fall Precaution for Moderate Risk
Patients
Identify as falls risk on
medical record and
include in shift
endorsement.
Assist and supervise
ambulation, Reinforce
to always call for
assistance.
Conduct hourly safety
checks.
Perform regular pain
assessment
Offer assistance to the
bathroom or use
bedpan hourly while
awake.
Evaluate for reversible
causes
• Orthostatic B.P
• Monitor Blood Sugar .
• Adequate Hydration
Check the patients
after the visitors leave
always.
Don’t lower the bed
side rails if any nurse
rise it up.
Patient Education. Family Education.
Apply Fall Risk Hand
Band

11. Standard Fall Precaution
for High-Risk Patients
Apply all low and moderate interventions.
Place a high risk for fall sticker/ label on the patient charts and patient room.
Raise Both upper and lower side rails.
Place mattress on floor.
Review the medication.
Assess the need of physical therapy consultation.
Assess the need for 1:1 monitoring as needed.

12. Patient and Family Education
both about the risk of falling, Safety Issues, and their Mobility
Limitation.
Educate
patient to make position changes slowly.
Teach
how important the family to be involving tin the patient safety.
Emphasize
what patient can do to be healthy, active, and independent
Emphasize
on

13. Interventions based on the fall-risk
assessment
Monitoring gait and mobility.
Bladder/ Bowel Training Program.
Fall Alert Medication.
Maintaining a safe environment.
Assistive Devices Monitoring.

14. Monitoring gait and mobility.
Normal/Safe Gait &
Balance.
Balance Problem
while Standing
Balance Problem
while Walking
Change in Gait
Pattern while
Walking through
doorway
Jerking/ Unstable
when Making Turn
Requires an
Assistance

15. Bladder /Bowel Training Program
45% Falls Identified as Toileting related (Tzeng, 2010)
Is a training technique for bladder and bowel to decrease urgency and
incontinence based on behavioral modification treatment techniques that
involves placing patient on toileting schedule.
• > 60 Years Old
• On Laxative
• Bed Ridden
• Postoperative

16. MEDICATIONS FALL ALERT
Pharmacist are responsible for reviewing medication and supplements
to ensure that the risk of falls is reduced
Notify the for Drug that depress the central nervous system may cause
sedation, drowsiness, ataxia, as well as paradoxical effects like:
• Antihistamine
• Antiepileptic
• Antidepressant
• Anticonvulsant
• Cardiovascular drugs

17. Maintaining a Safe Environment
Environmental hazards or hazardous activities are described as primary causes for
approximately half of all falls, which includes:
• Walking on slippery/rough surfaces.
• Obstacles.
• Inadequate light.
• Loose carpets.
• Trip Hazard regarding to medical care ( IV Tubing, Urinary Catheter, ).
Such hazards are likely to cause trips or slips in any age group but pose a particular
risk for community- dwelling elderly persons who may already have multiple
intrinsic risk factors for falls.

18. Assistive
Devices
Monitoring
Nurse Call
Bell

19. Fall Alert” Sign