FALL PREVENTION AND

MANAGEMENT
 Classification of falls:
* Accidental
* Anticipated physiologic
* Unanticipated physiologic *
Assisted fall

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).
 purpose

* Provides guidelines for preventing,

managing,
reporting fall occurrence
* To identify patient at risk of falling
* Determine actions to minimize risk factors
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
1) Red- high risk of falling color code
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
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
 materials
Assessment tool: Morse fall and Humpty
Dumpty scale
 logo
 fall incident assessment form
 OVR
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
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
 fall prevention and
management
 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

USE FLOOR SIGNS TO IDENTIFY SLIP RISKS

PLACE A NON-SLIP MAT OR DECALS ON THE FLOOR OF THE SHOWER OR BATHTUB AND A
NON-SLIP RUG ON THE FLOOR OUTSIDE THE TUB .

FOR BATHING, IT IS WISE TO USE A SHOWER SEAT OR BENCH, WHICH WILL HELP REDUCE
THE RISK OF A FALL WHILE SHOWERING

REGULAR NIGHT LIGHTS THAT PLUG INTO WALL OUTLETS ARE A GREAT CHOICE FOR
BATHROOMS, BEDROOMS, AND HALLWAYS.