D u k e Details - Advanced Clinical Practice - Duke University

Fall PreventionWhat actions do we take to reduce therisk of patient harm resulting from inpatient falls?Assess falls risk on admission or ambulatory check inand reassess every shift, or on transfer to another unit,or with change in care nurse.Assessment to include:• On admission, fall(s) in the last 12 monthsand every shift/visit• Alteration in mental status: confused, disoriented,impaired memory, unable to followcommands• Ability to ambulate to bathroom and back(excludes assistance with equipment, i.e., IVpole)• Other reasons patient may be at risk: medications– new or change in dose, blindness,incontinence, etc.Conduct safety checks every 2 hours on ALLinpatients. Remember the 5 Ps (Protect,Possessions, Pain, Potty and Partner) withyour safety checks.PROTECT• Keep bed in low position with wheels locked• Have 3 side rails up with rail at foot of bed onside near bathroom in down position (adults)or if < 4 yrs old, in a crib all 4 siderails must beup, or cognitively or physically impaired• Place IV pole on side of bed near bathroom,when possible• Keep path to bathroom clear and unobstructed• NIght light on at night• Use nonskid slippers26s