This document outlines a falls prevention program with the objectives of maintaining patient safety, reducing injury risk, and determining how falls occur. It defines falls and near falls, identifies individual and environmental risk factors, and describes a protocol for assessing falls risk upon admission and after changes. The protocol includes implementing standard precautions like raising bed rails, hourly checks, and education for low, moderate, and high risk patients. It also describes post-fall care and reporting procedures.

1. Falls Prevention Program
IPSG
Ahmad Thanin

2. Objectives
 To maintain patient safety.
 To reduce the risk of injury.
 To determine the way of the falls occurrence.
 To implement fall prevention program

3. Definitions
Falls:: unexpected falling down from
high position to lower position with or
without injury due to physical or mental
effect.
Near Fall: sudden loss of balance with
incomplete fall which include slips,
stumbles, or strip with ability to control .

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

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. • 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

7. Post Fall Protocol of Care
Implement the following intervention after
any fall:
• 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
• Orient the surrounding
environment.
• Provide Medication Information.
• Instruct patient to call for
assistance.
• Instruct to use the rubber – soled
shoes or non – slip footwear to
prevent slipping.
• 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
of falls.
• 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

10. 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.

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

12. Questions & Answers
Thank you