Guideline Title: Prevention of Falls (Acute Care)
Effective Date: May 2014
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council
I. Guideline Overview
This content is extracted from the adopted source document: Degelau, J., Belz, M., Bungum, L.,
Flavin, PL., Harper, C., Leys, K., Lundquist, L., Webb, B. (2012). Institute for Clinical Systems
Improvement. Prevention of Falls (Acute Care). Please refer to the source guideline for complete
Scope and Target Population
This protocol will include recommendations for a risk assessment for falls in hospitalized
patients, and will focus on the strategies and interventions required for the prevention of falls
and eventual elimination of falls with injury in acute care settings. The target population is
adult patients in an acute care setting.
1. Eliminate all falls with injury through a falls prevention protocol in the acute care setting.
(Annotations #1, 2, 3, 4, 5, 6)
2. Increase the percentage of patients who receive appropriate falls risk assessment and falls
prevention interventions. (Annotations #2, 6)
Clinician: all health care professionals whose practice is based on interaction with and/or
treatment of a patient.
Falls: a fall is defined as any unplanned descent to the floor.
Falls with injury: a five-point injury scale is recommended:
1. No apparent injury
2. Minor: bruises or abrasions as a result of the fall
3. Moderate: an injury that causes tube or line displacement, a fracture, or a laceration that
4. Major: injury that requires surgery or a move to intensive care unit for monitoring a life-
II. Practice Recommendations
The following recommendations are excerpted; for a complete list of recommendations, refer to the
complete source document.
Best practice in falls reduction includes:
o falls risk assessment
o visual identification of individuals at high risk for falls
o falls risk factor directed interventions
University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance
o standardized multifactorial education including visual tools for staff, families and
patients. (Anno-tations #1, 4, 5; Aims #1, 2)
o Teach back – a method of patient education that includes scripting such as "just to
make sure I did a good job in teaching you how to prevent a fall while you are here,
can you tell me the most important thing you can do to prevent a fall?"
There should be interdisciplinary collaboration on falls prevention at the time of admission
between admitting clinicians having first contact with the patient, including admitting
physicians, pharmacists and nurses. (Annotations #2, 4; Aim #2)
Incorporate team-based success factors associated with the best reported reductions in falls
and injury rates including:
o Ensuring falls risk assessments, investigation of falls incidents, confronting problem
issues, and accountability for missed opportunities.
o Interdisciplinary discussion of patient falls risk during daily rounding.
o Medication review for all patients at risk for injury and/or risk for falls.
o Nurse rounds to include reinforcement of education patients/families role in falls risk
prevention (use of call light, assist with ambulation to bathroom, etc.).
o Implementation of interdisciplinary post-fall huddle to discuss action plan after patient
Falls risk assessment (regardless of age) should include:
o a determination through the use of an assessment tool that the patient has fallen in
the past year,
o a functional assessment test,
o a visual observation of the patient's mobility for those not confined to bed rest, and
o an injury risk assessment.
III. Pertinent Resources
Policy 13.12A, Basic Care Standards (Inpatient Adults)
Policy 13.15AP, Fall Prevention for Inpatients (Adult & Pediatric)
Policy 13.16 Basic Care Standards-Inpatient Pediatrics (Birth-18 years of age)
Policy 5.0 Fall Prevention for Adults
B. Patient Education Resources
Health Facts For You (HFFY)
o HFFY Preventing a Fall in the Hospital (#5461)
o HFFY Staying Active While in the Hospital (#5625)
o HFFY What You Can do to Avoid Falls at Home (#5841)
o HFFY Preventing Falls While in the Hospital – Pediatrics (#6200)
o HFFY Falls and Older Adults (#6625)
o HFFY Home Safety – Preventing Falls (#6626)
o HFFY If You Fall (#6627)
C. Clinical Tools
Addendum: Care of the Hospitalized Pediatric Patient
Fall Prevention Equipment Guide
Safeguard Against Childhood Falls
Video Demonstrating Get Up and Go Test
See full guideline document for list of references.
V. Evidence Grading System
A. Primary Reports of New Data Collection:
Class A: Randomized, controlled trial
Class B: Cohort study
Class C: Non-randomized trial with concurrent or historical controls
Study of sensitivity and specificity of a diagnostic test
Population-based descriptive study
Class D: Cross-sectional study
B. Reports that Synthesize or Reflect upon Collections of Primary Reports:
Class M: Meta-analysis Systematic review Decision analysis Cost-effectiveness analysis
Class R: Consensus statement Consensus report Narrative review
Class X: Medical opinion
Citations are listed in the guideline utilizing the format of (Author, YYYY [report class]). A full
explanation of ICSI's Evidence Grading System can be found at http://www.icsi.org.