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FALL PRECAUTIONS

A patient fall is defined as an abrupt change in body position in a downward direction that may or may not result in physical injury.  A fall reduction program exists at SUNY Downstate Medical Center in effort to diminish the incidence of patient harm from fall while in the hospital.  This includes evaluation of the program’s effectiveness. The Joint Commission, which regulates patient safety policies through their hospital accreditation standards, has declared reducing the risk of patient harm resulting from falls as one of the National Patient Safety Goals.

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A significant portion of injuries in hospitalized patients, long-term care residents, and home care recipients results from falls.  Thus, the hospital evaluates each individual patient’s risk for falls and takes action to reduce the probability of a fall and subsequent injury.  The appraisal includes a patient’s past fall history, review of medications and alcohol consumption, gait and balance screening, assessment of walking aids, assistive technologies and protective devices, and environmental assessments.

The following are the National Patient Safety Goals elements of performance standards for decreasing the risk of falls in the hospital.

  • The hospital establishes a fall reduction program
  • The fall reduction program includes an evaluation appropriate to the patient populations, settings, and services provided.
  • The fall reduction program includes interventions to reduce the patient’s fall risk factors.
  • Staff receives education and training for the fall reduction program.
  • The hospital educates the patient and, as needed, their family, on the fall reduction program and any individualized fall reduction strategies.
  • The hospital evaluates the fall reduction program to determine the effectiveness of the program.

The Joint Commission - Helping Health Care Organizations help patients

In order to meet these goals, fall risk assessment must be made for each patient on each shift at SUNY Downstate or when there is a change in the patient’s medical or mental condition.  The nurses properly determine fall risk, as each patient record includes a fall assessment form.  Thus, patients are continually assessed and reassessed for risk of falling upon review of the patient’s mental status, physical condition, age, and number of past falls.  Hospital staff must also be attentive to any medications which may place the patient in jeopardy of falling.

The following is a list of medications that may impact the patient’s balance and increase their risk of falling in the hospital.

Psychotropic Medications

  • Amitryptyline                                                  orthostatic hypotension
  • Aripiprazole                                                   orthostatic hypotension
  • Chlorpromazine (Thorazine)                        orthostatic hypotension
  • Haloperidol                                                    hypotension
  • Olanzapine                                                     postural hypotension
  • Quetiapine                                                     postural hypotension
  • Risperidone                                                   orthostatic hypotension
  • Thiothixene                                                    orthostatic hypotension
  • Ziprasidone                                                   postural hypotension

Cardiovascular Medications

  • Carvedilol                                                       postural hypotension in elderly
  • Clonidine                                                        orthostatic hypotension
  • Methyldopa                                                    orthostatic hypotension
  • Doxazosin (Cardura)                                    orthostatic hypotension
  • Prazosin (Minipress)                                    orthostatic hypotension
  • Hydralazine                                                    hypotension
  • Labetalol                                                        postural hypotension (IV route)
  • Isosorbide Dinitrate                                      hypotension
  • Isosorbide Mononitrate                                orthostatic hypotension
  • Nitroglycerin                                                   light headedness, hypotension

Analgesics/Sedatives

  • Fentanyl                                                          hypotension
  • Codeine injection                                          hypotension
  • Meperidine (Demerol)                                  hypotension (frequent)
  • Oxycodone                                                     hypotension, light headedness
  • Midazolam                                                     drowsiness, oversedation
  • Lorazepam                                                    drowsiness, oversedation
  • Morphine                                                        hypotension
  • Hydromorphone                                            hypotension

Miscellaneous

  • Tamsulosin (Flomax)                                    orthostatic hypotension

The fall risk rating form, hourly rounding to check the patient’s status, and patient and family education are essential components of preventing falls and reducing their occurrence.  The patient is continuously evaluated for risk for fall.

SUNY Downstate Medical Center takes pre-emptive measures when patients are determined to be at risk for falls.  These actions are implemented based upon the patient’s score on the FALL RISK ASSESMENT FORM.  Listed below are the individual protocols for nursing interventions to prevent the incidence of falls in the hospital.

LOW RISK FOR FALLS

  • Keep bed in low position at all times
  • Call light to be kept within easy reach of the patient.  The patient is instructed to call for assistance when needed.
  • Turn on night light at bed time.
  • Instruct patient to sit up slowly prior to ambulation.
  • Instruct patient to use hand rails in bathrooms, showers, and hallways.
  • Recommend the use of non-skid slippers or shoes when ambulating.
  • Instruct patient to call for assistance prior to ambulating, if necessary.
  • Apply breaks to bed and wheelchairs.
  • Regardless of score, side rails must be kept in upward position to provide protection for patients who are over the age of 65, receiving narcotics or sedation, or who require the use of protective devices.

MODERATE RISK FOR FALLS

  • All of the above.
  • Position all equipment and supplies required for personal care (water pitcher, bed pan, urinal) within easy access for the patient.
  • Assist the patient when getting out of bed.
  • Interact with patient every two hours to see that personal needs are being met.
  • Document implementation of Protocol B on the Intervention Record at the end of each shift.

HIGH RISK FOR FALLS

  • All of the above.
  • Orient patient to environment every shift.
  • Keep side rails up at all times.
  • Document the implementation of Protocol C on the Intervention Record at the end of each shift.
  • Assess the patient every 30-60 minutes to ensure that personal needs are met.
  • Place high risk for fall sign on the patient’s door, place high risk for fall arm band on the patient’s wrist, and place high risk for fall red slippers on the patient’s feet.

STEPS TAKEN WHEN A FALL DOES OCCUR

In the instance of a fall, the incident is appropriately and accurately reported.  Patient falls are adverse events; hence, each is documented and reviewed as part of a preventative process.

In review of the event in which a fall does occur the environment in which the episode took place is surveyed and any hazards are noted.  Furthermore, the patient’s education, existing injury (if applicable), and activity at the time of fall are reviewed.

The National Database of Nursing Quality Indicators has established principle classifications for falls in the hospital.  These classifications establish standards for injury levels following fall.

  • None              the patient had no injuries resulting from the fall
  • Minor             resulted in application of dressing, ice, cleaning of a wound,      limb elevation, or topical medication
  • Moderate      resulted in suturing, application of steri-strips/skin glue, or splinting
  • Death             the patient died as a result of injuries sustained from the fall (not from physiologic events causing the fall)

Patient Fall Analysis Tool Part I

The staff and clinicians at SUNY Downstate Medical Center follow the protocols and procedures in effort to prevent patient falls.  In this effort the Joint Commission’s National Patient Safety Goals are consistently prioritized as to achieve maximum levels of safety for all patients during their stay in the hospital and any health care facility.

SUNY Downstate Medical Center