A Fall Prevention Plan Should Fit the Patient
Patients fall for different reasons. A patient who is confused may need different precautions than someone who is alert but physically weak.
Once the risks are identified, the hospital should develop a prevention plan based on that particular patient’s needs. Research supports individualized plans that address the patient’s specific risk factors rather than relying on the same precautions for everyone.
Depending upon the patient, precautions may include:
- making sure everyone caring for the patient knows the fall prevention plan
- educating the patient and family about the risk of falling;
- keeping the room and walking areas free of hazards;
- placing bed alarms to alert staff if a patient attempts to get out of bed;
- informing patient and family about the use of a call button;
- helping the patient get out of bed or walk;
- assisting patient with trips to the bathroom;
- keeping a walker or other needed equipment within reach; and
- appropriate monitoring and supervision of patient needs;
Communication is particularly important. Research on hospital fall prevention has found that incomplete, inconsistent communication among the care team can be a major barrier to reasonable care and that nurses, other caregivers, patients, and families need to work together.
Rules Matter Only When They Are Followed
A fall-risk score or a “Fall Risk” sign does not protect a patient by itself.
The hospital must take the information it has about the patient and turn it into action. The prevention plan must be communicated and consistently followed by the people actually caring for the patient. If the patient’s condition changes, the risks and precautions may need to be modified to meet the patient’s changed conditions.
If a fall does occur, the hospital should also determine why it happened and address the cause so that another fall can be prevented.
Falls and “Never Events”
The Centers for Medicare & Medicaid Services, or CMS, has taken special steps to address preventable injuries that occur in hospitals. CMS includes falls and trauma among its selected hospital-acquired conditions, including injuries such as fractures, dislocations and intracranial injuries.
Falls resulting in death or serious injury are recognized by CMS as “never events,” a term commonly used to describe serious reportable events that are generally identifiable, usually preventable, and may indicate a problem with a healthcare facility’s safety systems.
The designation of a fall as a “never event” does not mean that every hospital fall is preventable or that the occurrence of a fall automatically means someone did something wrong. Rather, it emphasizes the responsibility of healthcare organizations to establish, implement, and consistently use effective safety systems and evidence-based practices to reduce the risk of falls and prevent serious, avoidable harm.
Preventing the Fall Before It Happens
When a patient falls in a hospital, one of the most important questions is not simply how the patient fell, but what was known beforehand.
Did the hospital
- Recognize the patient as being at-risk?
- Develop a fall-prevention care plan that addressed the patient’s particular risks?
- Communicate the care plan to all the caregivers?
- Ensure that the fall-prevention care plan was followed?
Fall prevention begins with recognizing the danger and taking reasonable steps to protect the patient before the fall occurs.