Falls Risk – Part 1: assessment and precautions

A patient having a fall while in hospital is a known cause for delayed recovery, discharge and increased risk of injury and death.

It is not only the responsibility of the nurses caring for patients but the facility/organization and the healthcare team including physicians, physical therapists, occupational therapists, etc.; however, nurses are often the first line of assessment for patients in a healthcare setting.  Every nurse receives education on the importance of assessing a patient for the risk of falls and generally, there are standard assessment tools, and guidelines available and encouraged for use.

There are many risk factors for falls that should be considered including: a history of falls, age, mobility status, cognition, conditions affecting sensation or vision, low blood pressure, cardiac conditions, diabetes, other disorders or illnesses that cause changes in any of these categories, and pain, incontinence, medications- especially those that cause sedation, altered mental status or changes in blood pressure.

Every patient should be assessed for risk of falls at each point of care and for each visit including but not limited to in the emergency department, inpatient wards and outpatient procedure facilities.  This assessment should be documented, and the patient should have a universally recognized fall risk indicator depending on what the facility policy is.  Some examples of fall risk indicators are an armband indicating the person is at risk for falls, signage in a hospital room, red flags on the patient’s chart, a different colored gown, etc.

References –To read more about assessing a patient’s risk for falling and taking precautions see:

Quigley, P, Lunsford, B, et al. (2015). Focus on… Falls Prevention. American Nurse Today, 10(7), 28-33.