Risk Factors
This age group is at the highest risk of falling in hospitals.
What is older adults (65+ years)?
The most important item patients should wear to prevent slipping.
What are non-skid socks?
This equipment sounds an alarm if a patient attempts to leave the bed unassisted.
What is a bed alarm?
Falls should be reported within this timeframe.
What is immediately or within 1 hour?
This should be performed immediately after a patient falls.
What is assess the patient for injury?
Name two intrinsic fall risk factors.
What are muscle weakness and poor balance?
Hourly rounding checks often include these 4 P's
What are Pain, Potty, Position, partnership, Pump and Possessions?
This safety device is used to assist with patient transfers and ambulation.
What is a gait belt?
Before getting a patient up, staff should always check this.
What is the patient's fall risk score or care plan?
After a fall, always notify these persons.
What is the provider or physician, and manager?
This class of medications increases fall risk by causing dizziness.
What are sedatives or antihypertensives?
This visual cue is placed outside the room of high fall risk patients.
What is a fall risk sign or yellow signage?
This should be locked and within easy reach before assisting a patient to sit.
What is a wheelchair?
All fall incidents must be documented in this system.
What is JPSR?
Document this key detail about the fall in the chart.
What is the time, location, circumstances, and injury assessment?
This common nighttime condition increases fall risk.
What is nocturia (frequent urination at night)?
This type of mobility aid should always be within the patient’s reach.
What is a call light or walker?
Name one restraint alternative to prevent falls.
What is increased observation, activity engagement, or bed placement near nurse station?
This type of interdisciplinary meeting may be held after a serious fall.
What is Post-Fall Huddle?
This reassessment must be completed after a fall.
What is the fall risk assessment?
This tool is often used to assess a patient’s fall risk upon admission.
What is the Morse Fall Scale (or Hendrich II Fall Risk Model)?
Name 3 environmental factors that can be modified to reduce fall risk.
What are bed height, clutter, and lighting?
These should always be in place and secure when a bed is elevated.
What are side rails?
Policy often mandates this staff action before ambulating high-risk patients.
What is assistance from 2 staff members or use of assistive devices?
This type of post-fall review helps prevent future incidents.
What is a post-fall huddle or debrief?