Nurse Case Study
September 14, 2022
Nursing: Population, Public and Community Health
September 14, 2022

Falls Prevention

Falls Prevention


Tay Dove-Zoladz, Khushbu Patel, Laurie Hayes

Purdue University Northwest

College of Nursing

NUR 45200

Hi, This presentation is done by Tay, Khushbu, and Laurie. And our topic is falls prevention.


What are falls?

An unplanned descent to the floor with or without injury to the patient.

According to the agency for healthcare research and quality also known as AHRQ, defines falls as an unplanned descent to the floor with or without injury to the patient.


WHO states that falls are the second leading cause of unintentional injury deaths worldwide. In our case study,The interventions for fall prevention that were in place were not enough and the staff was not compliant with the implementation. This lead to an increase number of fall rates in the past year.

Depth & Breadth

700,000-1,000,000 falls annually

250,000 lead to fractures

11,000 deaths

$50 billion spent -non fatal fall injuries

$754 million- fatal falls



In general, experiencing falls after a surgery or in the hospital can be detrimental. WHO states that falls are linked to higher mortality rates, longer hospital stays, and increased healthcare costs.


AHRQ reports there are 700,000 to 1,000,000 hospital falls each year


Out of those falls, 250,000 falls lead to injuries and about 11,000 deaths occur. About 15% of falls cause bone fractures and injuries to the brain.


After these falls, there can be severe consequences faced by the patients and hospitals. In the past year, $50 billion was spent on nonfatal FALLS and $754 million on fatal falls. What is more important is that most fall cases are preventable and measures can be taken to prevent them from occurring. We will be talking more about this later in the slides.



Can be multifactorial




Can be for both patients and organization

Higher mortality rates

Longer hospital stays

Increased healthcare costs

Financial burdens

Legal consequences

Injuries (physical and emotional trauma)




To understand why the falls, occur and to prevent them, it is crucial to identify the potential causes. There can be many factors that can lead to falls. After these falls occur, the consequences that the patients and the organization have to suffer can be severe.

For the patients, it leads to longer hospital stays, financial burden that comes with increased costs, and they may also go through emotional and physical trauma.

For the organization and staff involved, they may have to go through legal consequences and increased costs as well.



Current Measures:

Admission assessment (hx)

Documentation (EMR) Q24hrs

Morse Fall Scale

Yellow Star


Root Cause Analysis identified potential causes for the rise in falls which included:


Implementation, Accuracy, Documentation


RN, CNA, Managers, Family/Visitors


Workload, Clutter, Lighting

Patient Factors

Post-Surgery Recovery, Medications, Acuity


Lack of, Reliable, Training




Month Our Unit Comparison Unit Comparison Unit
Jan 13 1 0
Feb 2 1 1
Mar 12 2 10
Apr 6 1 6
May 4 1 0
June 5 2 0
July 3 1 0
Aug 12 0 1
Sept 6 0 0
Oct 8 0 0
Nov 4 0 1
Dec 10 0 0
Mean 7.08 0.75 1.58
Median 6 1 0
Mode 12,6,4 1,0 0





Case study info

The issue!

Non-compliance with:

Current Measures


Let’s make a difference!


Multiple interventions

Proper monitoring of compliance.







As we know, being compliant with the protocols and policies in the hospital are important to ensure that all patients are receiving optimal care. Compliance ensures best results, IF they are proper rules in place and if there is a proper way to ensure compliance.. In our case study, it was mentioned that the yellow stars on the doors or the notices were not being changed. The case study also mentions of lack of communication between the staff members.





Indicator: What data will be collected:
Fall education and risk prevention. Interviews for knowledge and education assessment.
Hourly rounding on patients. Daily audits.
Bed alarms and call bells implementation. Randomized audits of EMAR and bedside compliance.
Yellow falling star indicator on patient door. Daily audits.
The Morse Fall Scale completed. Daily audits.



The indicators chosen to prevent falls on the medical-surgical unit are to educate patients on falls and preventative measures, the implementation of hourly rounding, activation of bed alarms and orientation of the call bell. As well as the application of a yellow star on the patient door to signal fall risk and lastly the completion of fall risk with the use of the morse fall scale. Data will be collected with the use of daily aduits, randomized audits, and interviews.

Plan for Improvement

Upon presenting to the Medical-Surgical unit patient will be educated on falls.


Patient will be assessed of fall rate with Morse Fall Scale.


Patient at high-risk for falls will have bed alarm on, yellow star outside door, and call bell within reach.


Hourly rounding will be completed throughout shift




Upon admission to the Medical-Surgical the patient will be educated on what a fall is defined as and the preventive measures that are implemented to prevent them. The patient will be assessed using The Morse Fall Scale to determine one’s likelihood of a fall. The Nurse will also activate the bed alarm and orient the patient on the call bell such as what it is for, how to use it and when. A falling yellow star will be placed outside patients door to inform staff that patient requires assistance with ambulation or may not be ambulatable. Despite fall risk level all patients are checked on hourly by staff to ensure safety and personal needs are met.


Orient the patient to surroundings, including use of call bell.

Educate patient on patient expectations on using call bell.

Place call light within reach.

Answer call light promptly.

Falling star outside the patient’s door.

Activated bed alarm.

Staff rounding every hour.

A fall risk assessment tool used.




Based on a patient’s level of fall risk different interventions need to take place. While other interventions are standard practices. It is standard practice to perform hourly rounding on a patient as well as orientate them to the room and the call bell system. It is also expected of the nurse on each admission to assess the patient’s risk for falls with a scale tool. If patient is moderate to high risk for falls other interventions such as bed alarm and falling star are activated to provide advance safety measures and surveillance.


Centers for Disease Control and Prevention. (2020, July 9). Cost of older Adult Falls. Centers for Disease Control and Prevention. Retrieved September 8, 2022, from

Preventing Falls in Hospitals. Content (March 2021). Agency for Healthcare Research and Quality, Rockville, MD.

World Health Organization. (2021, April 26). Falls. World Health Organization. Retrieved September 6, 2022, from,greatest%20number%20of%20fatal%20falls.























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