To maintain patient safety.
To reduce the risk of injury.
To determine the way of the falls occurrence.
To implement fall prevention program
Falls:: unexpected falling down from
high position to lower position with or
without injury due to physical or mental
Near Fall: sudden loss of balance with
incomplete fall which include slips,
stumbles, or strip with ability to control .
Most Causing to Falls
• Loss of consciousness.
• Orthopedic disorders.
• Anemia, Vision
• Drugs action.
• Post operative (sedation).
• Aging and sleeping habits
• Paralysis, TIA, CVA
• Unsafe higher position.
• Beds side rails.
• unlocked wheel chair.
• Water in the floor.
• Wire connections.
• Steps or stairs.
• Interfering Clothes
Patient Fall Injury Levels
• None: No injury.
• Minor: minor injury with abrasion or bruise
treated by dressing, limb elevation, topical
• Moderate: injury lead to Suturing or limping
treated by bandage, splinting, muscle or
• Major: which leads for casting, skin traction
and surgery, may need neurological and
• Death: the patient died as a result of
• UTD: unable to determine from the
• All in-patients will be assessed for the risk of fall upon admission.
• Reassessment is indicated for all of the following conditions:
- 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,
• Applying Risk Fall procedure for patients
- Hendrich 11 Fall risk for Adults.
- Humpty Dumpty Scale for Pediatrics.
• 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
Post Fall Protocol of Care
Implement the following intervention after
• First Aid.
• Ensure that patient is safe from further
• 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
• Patient and Family Education.
Standard Fall Precaution for Low Risk Patients
• Orient the surrounding
• Provide Medication Information.
• Instruct patient to call for
• Instruct to use the rubber – soled
shoes or non – slip footwear to
• Secure call bell, phone, bed table.
• Ensure the clothes are not
interfere with the patient mobility.
• Maintain the bed in the lowest
position and ensure bed and
wheelchairs are looked.
• Put side rails
• Conduct regular environmental
rounds in all areas surrounding
the patients to decrease the risk
• Keep bathroom light on and the
Standard Fall Precaution for Moderate Risk Patients
• Identify as falls risk on medical
record and include in shift
• Assist and supervise ambulation,
Reinforce to always call for
• Conduct hourly safety checks.
• Perform regular pain assessment
• Offer assistance to the bathroom
or use bedpan hourly while
• 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
Standard Fall Precaution for High Risk Patients
• Apply all low and moderate
• Place a high risk for fall sticker/
label on the patient charts and
• Raise Both upper and lower side
• Place mattress on floor.
• Review the medication.
• Assess the need of physical
• Assess the need for 1:1
monitoring as needed.
Patient and Family Education
• Educate both about the risk of falling, Safety Issues, and their
• Teach patient to make position changes slowly.
• Emphasize how important the family to be involving tin the
• Emphasize on what patient can do to be healthy, active, and