This document provides guidelines for preventing, managing, and reporting falls in a clinical setting. It outlines tools for assessing a patient's risk of falling, including the Morse Fall Scale and Humpty Dumpty Scale. Patients are categorized as high, medium, or low risk. Safety precautions and frequent monitoring should be implemented based on a patient's risk level. The document also describes procedures for responding to a fall, such as providing care and filing an incident report.

1. Prepared by:
Sojiya Jose
Clinical instructor in MCH, Alhasa, KSA

3. A fall is an unexpected
change in position that
causes a person to land
on an object on the
floor or other lower
level (witnessed), or is
reported to have landed
on the ground
(unwitnessed).
Classification of falls:
* Accidental
* Anticipated physiologic
* Unanticipated physiologic
* Assisted fall

4. * Provides guidelines for preventing, managing,
reporting fall occurrence
* To identify patient at risk of falling
* Determine actions to minimize risk factors

6.  all the patients should be assessed on admissions, and
patients in OPD and day surgery units, for risk for all using
Morse fall scale and Humpty Dumpty scale
Reassessment should be performed as the following:
• Beginning of the shift
• A change in patient's clinical status
• Post-operative and other procedure
• Whenever a fall occurs

7. 1) Red- high risk of falling
Morse fall : ˃55
humpty dumpty: 13-23
2) Yellow- medium risk of falling
Morse fall: 30-55
Humpty Dumpty: 7-11
• Green- low risk of falling
Morse fall:0-25
 Sticker logo should be attached to the patient’s file
 Laminated card board logo should be placed above the patient’s bed

8.  Safety precautions should be applied to all patients
 Do not leave at risk patient unattended in diagnostic or
treatment areas
 All the patient in recovery room of OR and ER observation
bed are at risk of fall and then the fall preventions should
be applied
 Patient having same risk of fall can be confined together in
one room if possible
 Patient status at risk should be communicated
 Fall risk incident rport should be submitted following any
fall to nursing office as apart of Quality Improvement
monitoring
 Preventive measures must be applied through health
education, periodic or regular environmental monitoring and
educational activities
 social worker can be contacted in case patient need
watcher

9.  Assessment tool: Morse fall and Humpty
Dumpty scale
 logo
 fall incident assessment form
 OVR

10. Pre-fall
 Assess and reassess patient with appropriate tool
 Educate family regarding family prevention
 Take actions to reduce risk for fall
 Correct potential risk in the patient fall
 Check the patient at least 2hourly and risk patients
every 30 minutes
 Encourage the patient to perform active range of
motion

11. Post-fall
 Guide the patient to remain supine and
support him
 Provide the psychological support
 Assess the patient and ABC’S
 Provide necessary care
 Observe the patient
 Inform supervisor
 Write OVR, fall incident report

12.  orient patient to surroundings and hospital routines
 patient and family education
 communicate the patient risk status
 place the patent's personnel belonging assistive device
aids with reach
 position call light accessible to patient
 instruct the patient slowly for supine position
 lower the bed to its lowest position, lock the bed
wheels, raise the side rails and observe patient
frequently
 keep bedside curtains open when nursing staff are not
in attendance
 call bell should be reachable to patient

13.  orient the patient and sitter to the surroundings
 instruct on use of bed controls, nurse call bell
 lower the bed to its lowest position, lock the bed wheels,
raise the side rails and observe patient frequently
 sitters will be encouraged not to sleep in the cribs
 maintain adequate lighting
 keep bedside curtains open when nursing staff are not in
attendance
 instruct patient and family to call for help when needed