Tools
Assessment
Fall Risk Identifiers
Diagnoses
Medications
100

This device should be present in every room and aids in supporting ambulation for patients that may have an unsteady gait.

What is a Gait Belt?

100

This assessment should be completed with each change of caregiver, post-op, and with any change in disposition.

What is the Morse Fall scale?

100

This color is what we use at TriHealth to identify a patient who is at risk for falling

What is yellow?

100

This procedure can alter the patient's electrolyte balance and indicates that the patient is at a high risk of falling.

What is dialysis?

100

This class of medications increases the risk of falling. Side effects include: increased ambulation due to frequency and urgency, orthostatic hypotension, and electrolyte imbalance

What are diuretics?

200

A device used for fall risks and designed to be an early warning sign that a fall could occur

What is a bed/chair alarm?

200

This assessment should be used by all caregivers each time a patient is ambulated and considers the patient's size, use of assistive device, functional ability, and extremities.

What is SAFE?

200

This should be on the wrist of every high fall risk patient at all times to alert team members that the patient is a fall risk.

What is a yellow fall risk bracelet?

200

This diagnosis places the patient at a high risk for massive blood loss, which makes the patient at a high risk for falling.

What is a GI bleed?

200

This class of medications increases the risk of falling. Side effects include: vasodilation, orthostatic hypotension, impaired perfusion and syncope.

What are Antihypertensives and/or Antiarrhythmics?

300

This should be initiated for all patients regardless of fall risk score. Includes: keeping patient care areas uncluttered, familiarizing the patient with the environment and placing the bed in a low and locked position

What are standard fall prevention interventions?

300
This should be used when considering a patient's risk for falling along with observation, instinct and communication. 

What is critical thinking?

300

These have non-slip pads on both sides to help prevent a patient from falling while ambulating.

What are yellow socks?

300

This can cause a fluid shift in the body, which can make the patient feel dizzy and weak.

What is bowel prep for a colonoscopy?

300

This class of medications increases the risk of falling. Side effects include: sedation, confusion, dizziness, orthostatic hypotension, altered gait and balance, and impaired cognition.

What are Analgesics/Narcotics

400

This tool can be used in the chair or bed as a gentle reminder to "call, don't fall."

What is a self release lap belt?

400

This tool helps to be proactive in attending to the patient's needs which can prevent falls.

What is purposeful hourly rounding?

400

This should be posted on the patients doorway to identify that a bed/chair alarm must be used.

What is fall risk signage?

400

This medical device placed to collect fluid can create a fluid shift and make a patient feel light headed when standing.

What is a drain?

400

This class of medications increases the risk of falling. Side effects include: muscle rigidity, impaired cognition, sedation and altered gait and balance.

What are Antipsychotics/Anticonvulsants?

500

This tool can help move a patient who is too unsteady to safely ambulate.

What is a Sara Stedy?

500

This is a simple screening tool used to distinguish whether a patient can be mobilized safely, or whether mechanical conveyance (lift assistance) is indicated.

What is the Dionne's Egress test?

500

This is included in the fall risk bundle and should be shared with the patient on admission.

What is the catch a falling star brochure?

500

This diagnosis can cause hypotension, fever, and confusion along with many other acute problems that increase the patient's risk for falling.

What is sepsis?

500

Caution should be used, particularly with older adults, with this common and often over-the-counter class of medication. Side effects include: sedation, confusion, constipation, paradoxical agitation and loss of balance.

What are Antihistamines?

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