[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Patient safety](https://durgical.com/en/nursing/areas/safety/) › Preventing falls: risk assessment and measures # Preventing falls: risk assessment and measures - Safe practice Each patient's fall risk is assessed, and measures for everyone are combined with extra measures for those at higher risk. Updated Nov 5, 2026 ## Key points - Assess risk on admission, with any change in condition, on transfer to another unit and after a fall. - Morse Fall Scale: one example of a fall-risk scale; it is used to find risk factors and plan measures. - Universal measures for everyone: low, locked bed, call bell within reach, non-slip footwear, lighting and a clear floor. - Targeted measures by risk: hourly rounds, scheduled toileting, help to walk, medication review, a bed alarm or a sitter. - Restraints are not a fall prevention measure: evidence does not show they prevent falls, and a restrained patient can still fall. ## What it is Falls inside the institution are a common adverse event and can cause hip fractures, head injury and even death. Most result from several factors together: a history of falls, mobility problems, confusion or delirium, frequent toileting needs, medicines that cause sedation or a drop in blood pressure on standing, and environmental hazards. The MinSalud technical guide asks that the fall risk of every admitted patient be classified, for example with the Morse Fall Scale, which helps identify each patient's risk factors and plan measures for them. Universal measures apply to every patient; targeted measures are added according to each person's risk factors. ## What it requires - History of falls. - Mobility problems, weakness or use of walking aids. - Confusion, agitation or sedation. - Frequent need to use the toilet, or incontinence. - Medicines that cause sedation, confusion, impaired balance or a drop in blood pressure on standing. - Unsafe environment: wet floor, clutter, poor lighting, stretchers without rails. ## Components - Universal measures: orient the patient to the room, bed in low position with brakes locked, call bell and personal items within reach, night lighting, a clean, dry and clear floor, non-slip footwear. - Targeted measures: scheduled hourly rounds, help with toileting on a routine, help or supervision to get up and walk, medication review with the pharmacist or doctor, bed or chair alarm, a sitter for an agitated patient. - Education: teach the patient and family about the fall risk and about activities out of bed, and involve the family with a drowsy or confused patient. - Never leave an at-risk patient unattended during transfers or in the bathroom. ## How it is applied (and why) - Assess fall risk on admission with the institutional scale: it shows the patient's risk factors, and each one points to a measure. - Apply the universal measures to everyone, without exception: falls usually come from several factors combined. - Orient the patient to the room, bathroom and call bell, and ask them to show you how to use it: if they cannot call for help, they will get up alone. - Leave the bed low and locked, with the call bell, urinal and water within reach: the patient can then meet basic needs without getting up alone. - Add targeted measures for the patient's factors: scheduled toileting for frequent toileting needs, help to walk for an unsteady gait. - Ask for a medication review for fall risk: some medicines cause sedation, confusion or dizziness on standing. - Educate the patient and family and record the measures in the care plan: every shift must apply them the same way. - Reassess risk with every change in condition, on transfer and after a fall: risk changes during the hospital stay. ## In nursing practice - If the patient falls, follow the institutional protocol, tell the nurse in charge and reassess fall risk. - Falls are the most commonly reported patient safety incidents; each one is reported and analysed to improve the process. - With a drowsy or confused patient, involve the family; a sitter at the bedside is an alternative to restraints. - Falls can cause hip fracture or head injury; that is why every fall is assessed carefully. ## Common mistakes - Applying the scale without turning the result into concrete measures. - Leaving the call bell or urinal out of reach. - Raising all bed rails as the only measure: rails raised to stop a patient getting up count as a restraint, and the need for rails is assessed for each patient. - Using restraints as a fall prevention measure. - Not reassessing risk after a clinical change. ## Test yourself Think of the answer, then tap the question to see it. ## What is the difference between universal and targeted fall prevention measures? Universal measures apply to every patient, such as a low, locked bed and the call bell within reach; targeted measures are added according to each patient's risk factors. ## Which validated scale is often used to assess fall risk in hospitalised patients? The Morse Fall Scale, among others. It is filled in on admission and helps identify risk factors and plan specific measures. ## Why are restraints not a fall prevention measure? Because evidence does not show that they prevent falls; a restrained patient tends to struggle and can fall or become entangled in the restraint. ## When should fall risk be reassessed? On admission, with every change in condition, on transfer to another unit and after a fall. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/preventing-falls-risk-assessment-and-measures/) ## Connections ## Related 2 - [Physical restraints: a last resort and their safe use](https://durgical.com/en/nursing/physical-restraints-a-last-resort-and-their-safe-use/) - [Patient safety in Colombia: the policy and its instructional packages](https://durgical.com/en/nursing/patient-safety-in-colombia-the-policy-and-its-instructional-packages/) [← All of nursing](https://durgical.com/en/nursing/) Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order. Sources: [Nursing Fundamentals, 5.6 Preventing Falls](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/05%3A_Safety/5.06%3A_Preventing_Falls) (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts edition, 2021); [Nursing Fundamentals, 5.7 Restraints](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/05%3A_Safety/5.07%3A_Restraints) (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts edition, 2021); [Guía técnica Buenas prácticas para la seguridad del paciente en la atención en salud, versión 1](https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/CA/guia-buenas-practicas-seguridad-paciente2010.pdf) (Ministerio de la Protección Social (MinSalud), Colombia, 2010); [Safety and efficacy of physical restraints for the elderly. Review of the evidence](https://pmc.ncbi.nlm.nih.gov/articles/PMC2146863/) (Canadian Family Physician (PubMed Central), 1996). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/nursing/preventing-falls-risk-assessment-and-measures/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/preventing-falls-risk-assessment-and-measures/