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Fall Risk Ward Protocol

The Male Medical Ward Fall Risk Assessment Protocol outlines systematic steps for assessing and preventing patient falls, involving nursing, physiotherapy, pharmacy, and medical teams. It includes initial screening at admission, triggers for reassessment, interventions based on risk levels, and documentation procedures. Daily safety checks are also emphasized to ensure a safe environment for patients.

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Bibiana Ayakem
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3 views2 pages

Fall Risk Ward Protocol

The Male Medical Ward Fall Risk Assessment Protocol outlines systematic steps for assessing and preventing patient falls, involving nursing, physiotherapy, pharmacy, and medical teams. It includes initial screening at admission, triggers for reassessment, interventions based on risk levels, and documentation procedures. Daily safety checks are also emphasized to ensure a safe environment for patients.

Uploaded by

Bibiana Ayakem
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Male Medical Ward – Fall Risk Assessment Protocol

This protocol provides clear steps for systematically assessing and preventing patient falls
on the male medical ward. It integrates nursing, physiotherapy, pharmacy, and medical
team actions to ensure patient safety.

1. Initial Screening at Admission (within 2 hours)


Goal: Identify patients at high risk of falls immediately upon arrival.

Step Action
1 Nurse completes initial falls history (previous falls, mobility aids, dizziness).
2 Perform quick screen: Morse Fall Scale + 4-Stage Balance Test.
3 Measure orthostatic BP if dizziness, hypotension, or antihypertensive use.
4 Flag high-risk patients with bedside alert and in shift handover notes.
5 Document findings in patient chart and electronic record.

2. Reassessment Triggers
Reassess fall risk when any of the following occur:
• Change in medical condition (e.g., new weakness, confusion, dizziness).
• New medications with sedative or hypotensive effects.
• After any patient fall, regardless of injury.
• Weekly reassessment for long-stay patients.

3. Interventions by Risk Level


Risk Level Key Actions
Low • Maintain safe environment.
• Educate patient on safe mobility.
• Regular rounding by nursing staff.
Moderate • Physical therapy referral for gait and strength assessment.
• Remove environmental hazards (clutter, cords).
• Review footwear and mobility aids.
High • Medication review by pharmacist.
• Bedside alarms or close observation.
• Scheduled toileting program.
• Ensure call bell and necessities within reach.

4. Documentation and Escalation


• Record all fall risk assessment results in patient chart with date and tool used.
• Notify multidisciplinary team of high-risk patients during shift handover.
• Conduct post-fall review within 2 hours to identify causes and prevention strategies.

5. Daily Safety Checks


• Check room for hazards: clutter, poor lighting, loose cords.
• Confirm mobility aids are correctly fitted and functional.
• Verify patient has appropriate non-slip footwear.
• Reassess cognition and mobility changes.

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