This document discusses fall prevention in patients. It defines falls and near falls. The objectives are to maintain patient safety and reduce injury risk by determining how falls occur and implementing prevention programs. Falls can be caused by individual factors like medical conditions, drugs, or aging, and environmental factors. Fall injuries are classified by level of severity from none to death. Risk assessment tools are used and precautions implemented based on a patient's risk level from low to high. Education of patients and families is also important for fall prevention.

1. Reducing the risk of patient
harm resulting from fall
Mr. Sushil Sudarshan Humane
MSN, Rn

2. 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 .

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

4. Most Causing
to Falls
Individual
• Most Causing to Falls
Individual
• Loss of consciousness.
• Orthopaedic disorders.
• Hypoglycaemia.
• Anaemia, 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. Risk Assessment
• All in-patients will be assessed for the risk of fall upon
admission.
• Reassessment is indicated for all of the following conditions:
o post operative.
o following procedural sedation.
o after administer medication.
o after blood transfusion.
o transferring patients between 2 units.
o after recording incident of fall.
o any changing in ambulatory status or elimination status,

7. Risk assessment
• 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

8. 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.

9. 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.

10. Standard Fall Precaution for Low
Risk Patients
• 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.

11. Standard Fall Precaution for
Moderate Risk Patients
• 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

12. Standard Fall Precaution for
Moderate Risk Patients
• 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
• Offer assistance to the bathroom or use bedpan hourly
while awake.

13. 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.

14. 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