Patient falls in a hospital setting are a significant safety concern and one of the most frequently reported adverse events in inpatient care. Falls often lead to serious injuries, such as fractures or head trauma, which can complicate recovery and increase the length of the hospital stay. Establishing standardized, rapid-response protocols is fundamental to maintaining patient safety. These structured procedures ensure every fall is managed with immediate attention and a methodical approach to minimize harm.
Immediate Stabilization at the Bedside
The staff member who discovers a patient fall must first call for immediate assistance using the hospital’s designated emergency system, often a Rapid Response Team call. Before any movement, the patient’s consciousness, breathing, and circulation must be quickly assessed to determine the need for basic life support measures. Do not move the patient until a spinal or severe injury is ruled out, as improper movement can worsen a fracture or spinal cord damage.
The immediate focus is to secure the scene and prevent further harm. This involves checking for obvious external signs of injury, such as bleeding, lacerations, or limb deformity, and covering the patient for comfort and privacy. Once the response team arrives, they will initiate a more detailed assessment, including a full set of vital signs. They will also check for environmental factors that may have contributed to the fall, such as wet floors or misplaced equipment.
The Post-Fall Medical Assessment
Once the patient is stabilized and safely moved, a comprehensive medical evaluation is initiated by a physician or advanced practice provider. This detailed assessment involves a head-to-toe examination to identify all potential injuries, including those that may not be immediately obvious. It is important to compare the patient’s current condition with their baseline status, especially regarding cognitive function and mobility.
A thorough neurological check is required, even if the patient did not strike their head. This assessment often includes using the Glasgow Coma Scale (GCS) to objectively measure eye-opening, verbal response, and motor response. For patients with a head injury or an unwitnessed fall, neurological observations must be performed frequently (e.g., every 30 minutes) to monitor for signs of intracranial bleeding or delayed deterioration. Diagnostic tests may be ordered to rule out internal injuries, such as X-rays of painful joints or a CT scan of the head for patients on anticoagulant medications.
Required Incident Reporting and Documentation
Following the medical assessment, two distinct forms of documentation must be completed: the medical chart and the incident report. The medical chart serves as the legal record of the patient’s condition and treatment, focusing strictly on the facts of the fall, physical findings, and subsequent medical interventions. This documentation records subjective complaints, objective data, and treatment orders, without speculation or assignment of blame.
The incident report, often called a safety or variance report, is an internal document used solely by the hospital’s quality and risk management teams. It collects information about the event, including contributing factors and witnesses, to identify system issues that may have led to the fall. This report is separate from the medical record and is intended for internal performance improvement and future prevention. Staff must also document that the patient and their family were notified of the fall and the patient’s current condition.
Systemic Review and Preventative Adjustments
The final step in managing a patient fall is the systemic review, which shifts the focus from the individual patient to the hospital’s safety processes. This review often begins with a post-fall huddle, a brief meeting of involved staff to determine the apparent cause and implement immediate changes. A more comprehensive review, such as a Root Cause Analysis (RCA), may follow to investigate deeper reasons for the fall, including medication side effects, lack of monitoring, or a poorly designed environment.
The findings of this review lead directly to adjustments in the patient’s ongoing care plan to mitigate recurrence risk. Preventative adjustments are customized and may include prescribing physical therapy to address balance issues or reviewing the patient’s medication list for drugs that cause dizziness. Environmental changes, such as bed exit alarms, floor mats, or a dedicated sitter, are also implemented as part of a multifactorial intervention strategy. Patient and staff education remains a highly effective prevention tool.