Patient Nurse Safety Fall Scale Notes (Week 1)

National Patient Safety Goals purpose

Reduce preventable harm by targeting patient identification, communication, medication safety, alarm safety, infection prevention, suicide prevention, and surgery safety.

Goal 1: Identify clients correctly

Use two approved patient identifiers before care, treatment, medication administration, or procedures.

Acceptable patient identifiers

Patient name, date of birth, designated hospital number/MRN, or personal telephone number, consistent with facility policy.

Unacceptable patient identifier

The patient's room number is not an approved identifier because patients can change rooms.

Open-ended identity verification

Ask, "Please tell me your name and date of birth," then compare with the ID band and medical record.

Goal 2: Improve staff communication

Use SBAR, closed-loop communication, read-back of orders, clarifying questions, and patient-centered communication.

SBAR

Situation, Background, Assessment, Recommendation: a structured way to communicate a patient concern.

Closed-loop communication

The receiver repeats back the information or order, and the sender confirms accuracy.

Goal 3: Use medications safely

Label medications and solutions, reduce anticoagulant errors, and maintain an accurate medication list.

Examples of high-alert medications

Anticoagulants and insulin; double-check these medications according to facility policy.

Medication reconciliation

Verify and communicate an accurate list of the patient's current and home medications.

Goal 4: Use alarms safely

Respond to alarms, evaluate the patient, maintain appropriate settings and volume, and recognize alarm fatigue.

Alarm fatigue

Reduced responsiveness caused by frequent alarms; never ignore or silence an alarm without checking the patient.

Goal 5: Prevent healthcare-associated infections

Use hand hygiene and prevention bundles to reduce CLABSI, CAUTI, SSI, and VAP.

CLABSI

Central line-associated bloodstream infection.

CAUTI

Catheter-associated urinary tract infection.

SSI

Surgical site infection.

VAP

Ventilator-associated pneumonia.

Goal 6: Reduce suicide risk

Screen for suicide risk, identify concerning verbal/nonverbal cues, remove hazards, and follow safety protocols.

Suicide-safety environmental hazards

Potential hazards include sharp objects and cords; remove hazards and follow the unit's observation protocol.

Goal 7: Prevent adverse events in surgery

Perform a surgical time-out, verify the right patient/procedure/site, mark the site when possible, and confirm written consent.

Surgical time-out

A pause before the procedure to verify the correct patient, correct procedure, and correct site with the team.

Patients at high risk for injury

Very young or older patients, patients with impaired gait, vision or communication problems, cognitive changes, behavioral disorders, or disabling medical conditions.

Fall-risk intrinsic factors

Weakness, unsteady gait, confusion, dizziness, low blood pressure, impaired vision, impulsiveness, and a history of falls.

Fall-risk medication examples

Opioids, sedatives, and antihypertensives can increase fall risk through sedation, dizziness, or hypotension.

Fall-risk environmental factors

High bed position, clutter, poor lighting, slippery floors, inaccessible call light, and toileting supplies out of reach.

Fall-risk medical equipment

IV tubing, oxygen tubing, and urinary catheters can create tripping hazards and restrict safe movement.

Morse Fall Scale purpose

A structured tool used to identify and document a patient's risk of falling.

Morse Fall Scale: history of falling

No history = 0 points; an immediate fall or a fall within the previous 3 months = 25 points.

Morse Fall Scale: secondary diagnosis

No secondary diagnosis = 0 points; a secondary diagnosis = 15 points.

Morse Fall Scale: ambulatory aid

Bed rest/nurse assist = 0 points; crutches/cane/walker = 15 points; furniture walking = 30 points.

Morse Fall Scale: IV or heparin lock

No IV/heparin lock = 0 points; an IV/heparin lock = 20 points.

Morse Fall Scale: gait/transferring

Normal/bed rest/immobile = 0 points; weak gait = 10 points; impaired gait = 20 points.

Morse Fall Scale: mental status

Oriented to own ability = 0 points; forgets limitations = 15 points.

Morse Fall Scale: no-risk score

0-24 points.

Morse Fall Scale: low-risk score

25-50 points.

Morse Fall Scale: high-risk score

51 points or greater.

When to document fall-risk assessment

On admission, after a fall, when the patient's condition changes, and according to facility policy.

Fall precautions

Non-slip footwear, low bed, call light within reach, fall-risk armband/signage, appropriate alarms, frequent rounding, and assistance with toileting/mobility.

Walker and safe ambulation

Ensure the appropriate assistive device is available and supervise or assist based on the patient's gait and ability.

Mr. Carter: immediate environmental hazards

Call light on the floor, bed in high position, and urinal across the room; correct hazards and assess breathing and confusion.

After a patient falls: first actions

Call for help and assess the patient for injury, level of consciousness, bleeding, possible fractures, vital signs, and safety.

After a patient falls: follow-up

Notify the provider, document/report per facility policy, and reassess fall risk and contributing factors.

Near miss

An event that could have caused harm but did not; report according to facility policy so hazards can be corrected.

Restraint definition

A mechanical or chemical intervention that restricts movement or normal access to one's body.

Mechanical restraint examples

Soft wrist restraints, mittens, restraint belt, vest, or side rails used with the intent to prevent voluntary exit.

Chemical restraint concept

A medication used to restrict behavior or movement rather than to treat the patient's condition, as defined by policy.

When restraints may be appropriate

Only after reasonable alternatives have failed and the patient poses an immediate risk to self or others or repeatedly removes essential devices.

Restraint alternatives

Reorientation, diversional activities, family presence, sitter, room near the nurses' station, bed/chair alarm, de-escalation, and frequent rounding.

Provider order for restraints

A provider order is required, and the order must be reevaluated every 24 hours.

Restraint order reevaluation

The provider reevaluates the restraint order every 24 hours, not every 48 hours.

Restraint assessment/documentation frequency

Every 2 hours, assess and document circulation, skin condition, assessment changes, patient symptoms, and the continued need for restraints.

Two-finger restraint rule

Maintain enough space to fit two fingers between the restraint and the patient's skin.

Restraint circulation warning signs

Numbness, tingling, pain, tightness, skin color changes, or other signs of impaired circulation.

Restraint attachment location

Use a quick-release method and attach the restraint to the movable bed frame; never tie it to a side rail.

Restraints and meals

Remove restraints during meals when safe and provide supervision/assistance as needed.

Restraints and toileting

Offer frequent toileting and remove restraints when safely assisting the patient to the bathroom or bedside commode.

Unnecessary urinary catheter

Do not request a Foley catheter merely to avoid assisting a restrained patient with toileting; it increases infection risk.

Side rails as restraints

Side rails are considered restraints when their intent is to prevent a patient from voluntarily getting out of bed.

When side rails are not restraints

When used to prevent an inadvertent fall during transport or when the patient cannot physically exit the bed, depending on intent and policy.

Four side rails and fall prevention

Raising all four side rails is not a routine fall-prevention intervention and may create entrapment or climbing risk.

Possible causes of seizures

Brain injury, infection, low oxygen levels, or low blood glucose levels.

Priority during a seizure

Protect the airway, breathing, circulation, and patient from injury while calling for help.

Positioning during a seizure

Assist the patient into a side-lying position when possible to protect the airway.

Protecting the head during a seizure

Place a pillow or towel under the head and remove nearby hazards.

What not to do during a seizure

Do not restrain the patient, do not place objects in the mouth, and do not leave the patient alone.

Seizure timing

Record when the seizure begins and how long it lasts.

Post-seizure monitoring

Assess airway, breathing, circulation, oxygen saturation, vital signs, and level of consciousness.

Seizure precautions: bedside equipment

Keep oxygen and suction equipment available at the bedside, maintain at least two IV sites when indicated, and recognize an aura when possible.

Seizure aura

A warning symptom that may occur before a seizure; recognize and report it if present.

Needlestick prevention

Do not recap used needles; activate safety devices and discard sharps immediately into approved containers.

Splash-risk situations

Cleaning diarrhea, emptying a bedpan, changing a saturated dressing, wound irrigation, or other tasks involving body-fluid spray.

Splash-risk PPE

Choose eye/face protection, gown, and gloves based on the anticipated body-fluid exposure.

Nurse ergonomics: bed height

Raise the bed to approximately waist level when providing care; lower the bed afterward for patient safety.

Nurse ergonomics: movement

Use lift devices, squat instead of bending, avoid twisting, maintain a wide base, and ask for assistance.

Preventing harm from patient violence

Review the patient's history/behavior, maintain a safe distance and clear exit path, use de-escalation, and report incidents.

Rapid response principle

Escalate sudden concerning changes in breathing, circulation, consciousness, or overall clinical status according to facility protocol.

Rapid response triggers

Sudden vital-sign changes, low oxygen saturation despite oxygenation efforts, chest pain, changed mental status or consciousness, or a seizure aura.

Hospital Code Blue

Medical emergency, such as cardiac arrest.

Hospital Code Red

Fire or smoke emergency.

Hospital Code Gray

Combative or violent patient.

Hospital Code Brown

Hazardous spill.

Hospital Code Yellow

Missing patient or visitor.

Hospital Code Pink

Infant or child abduction.

Hospital Code Orange

Mass casualty or disaster.

Hospital Code Green

External disaster affecting the hospital.

Hospital Code Black

Bomb threat or suspicious package.

Hospital code safety caveat

Hospital color codes may differ by facility; learn and follow the specific facility's emergency-code policy.