PSF-SOP-001: Falls Risk Assessment and Prevention

At a glance

• Assess every patient for falls risk on admission, using the falls risk assessment tool (PSF-FRM-002).
• Identify the risk factors and set interventions for each one. Write them in the care plan.
• Review the assessment daily, and after any change in condition, medicine or location.
• After any fall, check the patient at once, inform the doctor, and record it on PSF-FRM-001.
• Review the falls log every month and report trends.
• Stop and get help straight away if: the patient has a fall with a head strike, new weakness, severe pain, or reduced consciousness. Call the doctor at once and follow the hospital head-injury procedure.

Step 1. Complete the initial falls risk assessment within the first hours of admission.

• Use PSF-FRM-002. Ask the patient about previous falls, mobility, continence, vision and hearing, and dizziness.
• Check the medicine chart for sedatives, antihypertensives, diuretics, opioids and any medicine that causes low blood pressure or drowsiness.
• Assess cognition: is the patient confused, does the patient remember the call bell?
• Score the tool and classify the risk using the bands.

Key point: Assess early. Most falls happen when the patient is new to the ward and unfamiliar with the environment (EC).

Step 2. Set the interventions for each risk factor.

• For each positive item, write one intervention in the care plan (for example, bed in low position; call bell within reach; supervision when walking; toileting schedule; footwear checked).
• If a medicine increases risk, ask the doctor to review it within 24 hours and record the request.
• If a patient has a mobility problem, request physiotherapy or occupational therapy assessment for equipment and exercise.

Key point: Interventions must match the risk. Generic lists that are not checked for each patient do not prevent falls.

Step 3. Communicate the risk to the team and the patient.

• Mark high-risk status on the ward board or the electronic record, as the hospital uses.
• Tell the patient and family what to do and what to ask for (for example, call before getting up at night).
• Record the handover at each shift for high-risk patients.

Key point: The whole team must know who is at risk, not only the person who did the assessment.

Step 4. Review the assessment daily and after any change.

• Review every patient at least once each day.
• Review again after: a fall or near fall, a new medicine that increases risk, a change in mobility or consciousness, a transfer to another area, or return from theatre.
• Update the score and interventions. Record the date and initials.

Key point: Risk changes with illness, medicines and time in hospital. A single assessment is not enough.

Step 5. Respond immediately to any fall.

• Do not move the patient unless they are in danger. Check breathing, consciousness, and injury.
• Call for help and inform the nurse in charge and the doctor.
• If there is a head strike, a patient on anticoagulants, new weakness, severe pain or reduced consciousness, call the doctor urgently and follow the head injury procedure.
• Help the patient up only after the doctor has assessed them, unless it is safe and they are not injured.

Key point: The first check after a fall decides whether there is serious injury. Do not rush the patient up.

Step 6. Record and review every fall.

• Complete PSF-FRM-001: date and time, location, cause (as far as known), injury, response, doctor informed, review date.
• Repeat the falls risk assessment and update interventions the same day.
• Report to the ward head. Complete an incident report (INC-POL-001) for every fall with harm, and for every fall of a high-risk patient.
• Root-cause review within 72 hours for any fall with harm (EC).

Key point: Every fall is a learning opportunity. Records must be specific enough to change the next intervention.

Step 7. Review the falls log monthly.

• The chief nurse reviews all falls each month, looks for patterns (time, location, medicine, equipment), and sets actions.
• Report the number of falls and falls with harm to the quality committee.

Key point: Patterns show what the single assessment misses, such as a ward with poor lighting or a medicine given at night.