Reference — Patient Safety
Fall Risk Reference
Patient falls are the most common adverse event in hospital settings and a leading cause of injury-related morbidity. Understanding risk factors and implementing evidence-based interventions is a core nursing responsibility.
Educational use only. Fall prevention protocols vary by facility. Always follow your institution's fall risk policy and individualize interventions based on clinical assessment and validated scoring tools. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Fall Risk Factors
| Category | Examples |
|---|---|
| Intrinsic (Patient) | Age ≥ 65, history of falls, altered mental status, impaired gait or mobility, muscle weakness, visual/hearing impairment, urinary urgency/incontinence, orthostatic hypotension, acute illness or dehydration |
| Medications | Sedatives/hypnotics, opioids, antihypertensives, diuretics, antidepressants, antipsychotics, antihistamines, antiepileptics — multiple medications (polypharmacy ≥ 4 drugs increases risk) |
| Extrinsic (Environment) | Wet floors, poor lighting, cluttered pathways, high beds, unfamiliar environment, lack of assistive devices, inadequate footwear |
| Diagnosis-Related | Stroke, Parkinson's, dementia, delirium, diabetes (neuropathy), COPD, cardiac conditions, post-operative state |
Universal Fall Precautions (All Patients)
These interventions apply to every admitted patient regardless of fall risk score:
- Bed position: lowest setting, side rails up (per order/policy), wheels locked
- Call light: within reach; patient instructed on use and taught to call before getting up
- Footwear: non-skid socks or shoes; patient not to ambulate in bare feet or socks without grip
- Environment: clear path to bathroom; adequate lighting; personal items within reach
- Orientation: orient patient to room layout and how to call for assistance on admission and after any room change
- Hourly rounding: address Pain, Position, Personal needs (toileting), and Placement (call light) — the “4 Ps”
Tiered Interventions by Risk Level
| Risk Level | Score (Morse) | Additional Interventions |
|---|---|---|
| No Risk | 0 – 24 | Universal precautions only; routine nursing care |
| Low Risk | 25 – 44 | Standard fall prevention interventions; patient and family education; reassess with condition changes |
| Moderate Risk | 45 – 54 | Fall-risk armband and door signage; bed alarm on; assisted ambulation with gait belt; medication review |
| High Risk | ≥ 55 | All above + consider 1:1 sitter; strict assistance for all mobility; frequent reassessment; multidisciplinary review |
Key Bedside Interventions
- Toileting schedule: offer toileting assistance every 2 hours — most falls occur during attempts to reach the bathroom.
- Medication review: identify and communicate fall-risk medications to the provider; request medication reconciliation or substitution when appropriate.
- Assistive devices: ensure walker, cane, or wheelchair is accessible and correct for the patient; verify patient knows how to use it.
- Strength and mobility: collaborate with physical therapy (PT) for gait training and strengthening exercises as ordered.
- Delirium prevention: orient frequently, maintain sleep-wake cycle, encourage mobility, minimize sedating medications — delirium greatly increases fall risk.
- Vision and hearing: ensure glasses and hearing aids are used; correct sensory impairment before ambulation.
Post-Fall Assessment
If a patient falls, respond systematically before moving the patient:
- Do not move the patient until injury is assessed — stabilize the cervical spine if head or neck injury is suspected.
- Assess level of consciousness and orientation; check pupils and motor responses.
- Assess for injury: head, neck, back, hips, extremities — palpate for tenderness, deformity, swelling.
- Check vital signs; assess for pain.
- Notify the provider; obtain orders (imaging if injury suspected).
- Complete thorough nursing documentation of the event, assessment findings, and all notifications.
- File an incident report per facility policy (not referenced in the medical record).
- Reassess and update fall prevention plan to address the identified contributing factors.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with The Joint Commission — National Patient Safety Goals · Agency for Healthcare Research and Quality (AHRQ) · Institute for Safe Medication Practices (ISMP). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →