Loss of upright position that results in landing on the floor, ground or an object or furniture or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or stair.
Loss of balance as a result of slippery surface that does not result in a fall.
Loss of balance due to knees giving way or other reasons but does not result in a fall.
Loss of balance due to a specific obstacle that does not result in a fall.
- Hazardous activities
- Time of day
- External lighting
- Loose electrical cords
- Muscle and strength weakness
- Gait and balance disorders
- Visual disturbances
- Cognitive impairment/Mental status alterations
- Postural hypotension
- Chronic disease
Fall Risk Assessment
If any of these medical factors are present, go to Standard Fall Prevention Interventions:
- Agitation/Delirium- infection, toxic/metabolic, cardiopulmonary change, CNS, dehydration/ blood loss, sleep disturbance
- Meds (dose/timing)-psychotropics, CV agents (digoxin especially), anticoagulants(increased risk of injury), anticholinergic, bowel prep
- Orthostatic hypotension, autonomic failure
- Frequent toileting
- Impaired mobility
- Impaired vision, inappropriate use of assistive device/footwear
- History of Falls (CV/light headed-dizzy, Dysequilibrium- loss of balance with no abnormal motion sensation, Vestibular/Vertigo, Weakness-Musculoskeletal/give way, combination, other)
- Psychotropics, digoxin, type 1a antiarrhythmic, diuretic (thiazides>loop diuretics)
- Antihistamines/benzodiazipines- withdrawal has shown decrease in falls risk, assess for sleep disorder, avoid routine PRN orders-try non-pharmacological approaches including quiet sleep protocols on units
- Antidepressants- Tricyclics higher risk than SSRI, but SSRI’s have risk as well, high level of phenytoin; low dos amitriptyline affects gate; gabapentin 10-25% ADR
- Cardiac drugs/antihypertensives- if orthostatic (drop in sys>20 mm in 3 min) and symptomatic
- Anticoagulants – subdural hematomas are rare; avoid only if very unstable gait or balance, concurrent use of alcohol, or other drugs that interact and increase bleeding, or non-compliant with regimen or lab follow up
- Drugs treating nocturia (consider tamsulosin due to lower risk of orthostasis)
Standard Fall Prevention Intervention
Low risk :
- Assess patient’s fall risk upon admission, change in status, transfer to another unit and discharge.
- Assign the patient to a bed that enables the patient to exit toward his/her stronger side whenever possible.
- Assess the patient’s coordination and balance before assisting with transfer and mobility activities.
- Implement bowel and bladder programs to decrease urgency and incontinence.
- Use treaded socks for all patients.
- Actively engage patient and family in all aspects of Fall Prevention Program.
- Instruct patient in all activities prior to initiating assistive devices.
- Teach patient use of grab bars.
- Instruct patient in medication time/dose, side effects, and interactions with food/medications.
- Lock all moveable equipment before transferring patients.
- Individualize equipment specific to patient needs.
- Place patient care articles within reach.
- Provide physically safe environment (eliminate spills, clutter, electrical cords, and unnecessary equipment).
- Provide adequate lighting.
- Evaluate and treat gait changes, postural instability, spasticity.
- Initiate treatment for impaired vision, hearing.
- Evaluate medication profile for fall risk.
- Evaluate and treat pain.
- Evaluate and treat orthostatic hypotension.
- Assess and treat impaired central processing (dementia, delirium, stroke, perception)
High risk :
- Consider use of: technology for fall prevention , non-skid floor mat, raised edge mattress.
- Clear patient environment of all hazards
- Review medications for fall risk and adjust as indicated
- CV agents – if orthostatic (drop in systolic > 20 mm in 3 minutes) and symptomatic
- Discontinue HCTZ, liberalize sodium in diet
- If ACE inhibitor appropriate, use agent with less renal metabolism (fosinopril)
- If Calcium channel blocker – NOT nifedipine
- If ß blocker – not cardioselective / not metoprolol / atenolol; use pindolol / propranolol
- Consider referral to services such as physical medicine and rehabilitation, audiology, ophthalmology, cardiology.
- Optimize treatment of underlying medical conditions.
- Evaluate and treat for pain.
- Evaluate circumstances surrounding fall for extrinsic and intrinsic contributing factors.
- Home safety
Plan for emergency fall notification procedure.
After a patient falls
- Assess for injuries (e.g. abrasion, contusion, laceration, fracture, head injury) and determine Level of Injury.
- Obtain and record sitting/standing vital signs.
- Assess for change in range of motion.
- Alert Physician.
- Follow organizational policies for patient monitoring.
- Document circumstances in medical record.
- Complete incident report.
- Assess intrinsic and extrinsic factors.
- Notify all team members of patient fall..
- Assess and treat any injury.
- Initiate diagnostic and treatment interventions for contributing causes.
- Determine probable cause of fall (history, physical factors, medications, laboratory values).
- Consult appropriate services.
- Evaluate and treat for pain.
- Document circumstances in patient medical record.
- Patient appearance at time of discovery
- Patient response to event
- Evidence of injury
- Medical provider notification
- Medical/nursing actions
- Complete Occurrence Variance Report (OVR)
- Notify Nurse Manager or designee
- Department of Veterans Affairs. (1996, June). Clinical practice guidelines: The prevention and management of patient falls. Tampa, Fl: Author.
Hendrich, A, Nyhuis, A, Kippenbrock, T, et al, (1995). Hospital falls: Development of a predictive model of clinical practice. Applied Nursing Research , 8. 129-139.
Hoskin A.F. (1998). Fatal Falls: Trends and Characteristics. Statistical Bulletin, Apr-Jun, 10-15.
Maki, B.E. (1997). Gait changes in older adults: Predictors of falls or indicators of fear? Journal of American Geriatrics Society, 45 , 313_20.
Morse J. (1997). Preventing patient falls . Thousand Oaks, CA: Sage.
National Safety Council. 1999. Report on Injuries in America . Itasca, IL.
Rawsky, E. (1998). Review of the literature on falls among the elderly. Image , 30(1), 47-2.
Steven, J, & Olson, S (1999, October). Check for safety. A home fall prevention checklist for older adults. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
Tideiksaar, R (1997). Falling in old age. Its prevention and management . (2nd ed). New York: Spinger Publishing.
VA National Center for Patient Safety (NCPS). (2000).
VISN 8 Patient Safety Center. (January 2001). Proceedings: Promoting Patient Freedom and Safety: Preventing Falls. VISN 8 Patient Safety Center of Inquiry: St. Pete Beach, FL.
VISN 8 Patient Safety center of Inquiry.(1998).
Dr. Khalid Abulmajd
Healthcare Quality Consultant