Patient Safety and Fall Prevention in a Hospital Setting

Patient Safety and Fall Prevention in a Hospital Environment

A Practical Guide for Healthcare Professionals, Managers, Patients, and Companions

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Introduction

Patient falls are one of the most frequent adverse events in healthcare settings and represent a significant challenge for care safety. In addition to the risk of injuries, fractures, and traumas, a single fall can prolong hospitalization, increase hospital costs, compromise clinical recovery, and reduce patient trust in the institution.

While many falls are classified as preventable events, their prevention requires much more than simply installing bed rails or orienting the patient. It is necessary to understand that most accidents result from a combination of various factors, such as clinical conditions, medications, functional limitations, the hospital environment, equipment used, and even the actions of companions.

Various national and institutional protocols converge on the same principle: fall prevention is the responsibility of the entire multi-professional team, with active participation from the patient and their family.

This guide compiles the main recommendations from official Brazilian protocols and transforms them into practical guidelines, operational tables, checklists, and examples from daily hospital life.

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Chapter 1 – Overview of Hospital Falls

Impact of falls

Consequence	Impact
Minor injuries	Abrasions, bruises, and contusions
Moderate injuries	Lacerations, sprains, and need for sutures
Serious injuries	Fractures, head trauma, and hemorrhages
Care impact	Increased length of hospital stay
Economic impact	Increased use of hospital resources
Emotional impact	Fear of walking, loss of autonomy, and anxiety
Institutional impact	Indicator of care quality and patient safety

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Where do falls happen most frequently?

Location	Risk level
Room / Ward	🔴 Very High
Bathroom	🔴 Very High
Corridors	🟠 High
Transport between sectors	🟠 High
Wheelchair	🟠 High
Bed-to-chair transfer	🔴 Very High
Nursery / Pediatrics	🔴 Very High
Rooming-in	🟠 High

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The 10 highest-risk fall situations

Situation	Risk
Getting up to go to the bathroom unassisted	🔴
Using an IV pole as support	🔴
Walking in socks only	🟠
Wearing loose-fitting slippers	🟠
Getting up immediately after surgery or sedation	🔴
Wheelchair with unengaged brakes	🔴
Side rails down for at-risk patient	🔴
Wet floor	🔴
Personal items out of reach	🟡
Child sleeping with companion in the same bed	🔴

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What is considered a fall?

According to Brazilian patient safety protocols, a fall is the unintentional displacement of the body to a lower level, which may occur with or without injury, and even when the patient is caught before fully reaching the ground.

Classification of falls

Type	Characteristics
No harm	Does not cause apparent injuries
Mild harm	Abrasions or bruises
Moderate harm	Lacerations, need for sutures or immobilization
Severe harm	Fractures, head trauma, or hemorrhages
Death	Fatal outcome related to the fall

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Reverse Engineering of Falls

A fall rarely has a single cause. Most of the time, several factors occur simultaneously.

Example

Inpatient
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Took sedative medication
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Needed to go to the bathroom
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Did not call nursing staff
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Was wearing slippers
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Partially wet floor
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FALL

This approach demonstrates that prevention depends on the early identification of all contributing factors, not just the patient's clinical condition.

Dental Access Alert: Most falls do not happen because the patient "lost their balance." They result from a combination of clinical, environmental, and behavioral factors. Identifying this combination is the most effective way to prevent accidents.

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Who is most at risk?

Profile	Risk level
Elderly	🔴 Very High
Sedated patients	🔴 Very High
Immediate post-operative	🔴 Very High
Neurological deficit	🔴 Very High
Cognitive changes	🔴 Very High
Young children	🟠 High
Pregnant and postpartum women	🟠 High
Patients with gait difficulties	🔴 Very High
Use of multiple medications	🟠 High

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The role of the multi-professional team

Professional	Main responsibilities
Nurse	Risk assessment, care plan, and guidance
Nursing Technician	Application of preventive measures and monitoring
Doctor	Clinical assessment and therapeutic review
Physiotherapist	Assessment of gait and balance
Pharmacist	Review of medications associated with risk
Occupational Therapist	Strategies for safe mobility
Nutritionist	Assessment of nutritional conditions influencing strength and recovery
Companion	Follow instructions and request assistance whenever necessary

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Chapter 2 – How Falls Happen in Practice

Fall prevention begins with understanding how accidents truly occur. In practice, a fall is rarely caused by a single factor—it results from a combination of clinical conditions, environment, equipment, medications, and the behavior of the patient or companion.

Therefore, we adopt a reverse engineering approach here: instead of just asking "what are the risk factors?", we answer "how did this accident happen?".

The five elements that precede a fall

In most cases, a fall involves a combination of one or more of these elements.

Element	Examples
Clinical condition	Weakness, dizziness, hypotension, pain, neurological alteration
Medications	Sedatives, antihypertensives, opioids, diuretics
Environment	Wet floor, inadequate lighting, obstacles
Equipment	Chair without brakes, lowered rails, IV pole, cables
Behavior	Getting up alone, haste, overconfidence, lack of guidance

The greater the number of factors present simultaneously, the higher the probability of a fall occurring.

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Situation 1 – The patient got up to go to the bathroom alone

This is one of the most frequent situations in hospitals.

How the accident typically happens:

Patient wakes up during the night
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Urgent need to urinate
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Does not want to bother the staff
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Gets up quickly
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Dizziness upon standing
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Loses balance
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FALL

Factor	Contribution
Diuretics	Increase urinary frequency
Postural hypotension	Causes dizziness upon standing
Sedatives	Reduce reflexes
Dark environment	Makes it difficult to see obstacles
Haste	Reduces attention
Lack of assistance	Increases the risk of losing balance

How to prevent:

• Instruct on using the call bell.
• Assist high-risk patients with bathroom visits.
• Maintain adequate nighttime lighting.
• Assess for postural hypotension.
• Provide assistive devices when indicated.

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Situation 2 – The IV pole became a "crutch"

This is a very common scene. The patient believes the IV pole offers stability similar to a walker. In reality, the exact opposite occurs.

Patient gets up
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Holds the IV pole
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Equipment moves
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Patient loses balance
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Pole tips over
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FALL

In addition to the fall, the following can occur:

Consequence	Risk
Dislodgement of venous access	Very high
Loss of access	High
Extravasation of medications	High
Tipping of infusion pump	High
Impact injuries	High

Correct conduct:

• Never use the IV pole as a walking aid.
• Request assistance from the staff.
• Use a walker or other appropriate device when indicated.

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Situation 3 – Walking in socks only

Many patients believe that walking in socks only is more comfortable. In reality, hospital floors generally have a smooth finish to facilitate cleaning and disinfection, reducing friction compared to non-slip flooring.

Situation	Consequence
Waxed or polished floor	Slip
Wet floor	Fall
Change of direction	Loss of grip

Prevention:

• Use non-slip socks.
• Wear closed-toe shoes with non-slip soles.

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Situation 4 – Inadequate slippers

Slippers are among the most commonly used footwear by inpatients. They are also among the least safe.

Error	Consequence
Loose slippers	Foot slips out easily
Worn sole	Reduced grip
Wet slipper	Slipping
Inadequate size	Tripping

Prioritize closed-toe shoes or non-slip socks when appropriate.

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Situation 5 – Objects out of reach

Many falls happen while the patient is still in bed. The patient tries to reach for a cell phone, remote control, glass of water, call bell, glasses, or charger. By leaning too far, they lose balance, slide, and fall out of bed.

Item	Action
Call bell	Always within reach
Water	Close to the patient
Cell phone	In a safe place
Personal items	Organized bedside table

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Situation 6 – Wet floor

Cleaning is not always the cause. The floor can become wet from bathing, leaks, urine, intravenous solutions, or room cleaning.

How to prevent:

• Signal immediately.
• Remove excess water.
• Accompany patients during ambulation.

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Situation 7 – Bed-to-chair transfer

One of the most critical activities.

Error	Consequence
Brakes disengaged	Chair moves
Patient stands quickly	Dizziness
Lack of assistance	Loss of balance
Wet floor	Slip

Checklist:

• Brakes engaged.
• Appropriate footwear.
• Team positioned.
• Clear environment.
• Patient oriented.

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Situation 8 – Newly operated patient

After surgery, hypotension, weakness, drowsiness, and residual effects of anesthesia can occur.

Recommendation: never encourage the patient to walk without prior assessment by the team.

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Situation 9 – Child trying to get out of bed

This is one of the main causes of falls in pediatrics.

Situation	Risk
Rails down	Very high
Child playing on the bed	Very high
Child trying to reach toys	High
Distracted companion	High

Preventive measures:

• Raised bed rails when indicated.
• Constant supervision.
• Objects within reach.
• Guidance for guardians.

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Situation 10 – Companion sleeping in the same bed as the child

Although many companions do this to reassure the child, this practice can significantly increase the risk of accidents.

Situation	Possible consequence
Adult changes position during sleep	Child is moved to the edge of the bed
Bed rails remain lowered	Fall from bed
Child tries to get up unnoticed	Fall
Reduced space	Compression and loss of stability

Good practices:

• Use the armchair or bed designated for the companion, when available.
• Keep the child accommodated in a bed appropriate for their age.
• Keep bed rails raised as indicated by care.

Important: This guidance aligns with the principles of fall prevention protocols and good patient safety practices. As previously mentioned, there is no explicit federal regulation prohibiting companions from sleeping in the same bed, but this practice is not recommended as it increases the risk of accidents.

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Chapter Summary – The most common falls have something in common

Situation	Could it have been avoided?
Getting up alone	✅
Walking while using an IV pole for support	✅
Using inappropriate slippers	✅
Walking only in socks	✅
Wet floor	✅
Objects out of reach	✅
Inadequate transfer	✅
Child unsupervised	✅
Lowered bed rails	✅
Companion mobilizing patient alone	✅

The vast majority of hospital falls do not result from a single error, but from the sum of small risk factors. Identifying these situations before they occur is the most effective strategy to reduce accidents and promote safer care.

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Table 1 – The main fall situations in a hospital environment

No.	Situation	How the accident happens	Main factors involved	Possible consequences	Preventive measures	Related products and equipment
1	Getting up to go to the bathroom alone	The patient gets up without asking for help, usually at night	Sedation, orthostatic hypotension, urinary urgency, weakness	Fall from own height, trauma and fractures	Instruct on call bell use, accompany at-risk patients, and maintain adequate lighting	Call bell, grab bars, commode chair
2	Using an IV pole for support	The patient uses the IV pole as if it were a walker	Equipment instability and loss of balance	Fall, venous access traction, and equipment damage	Never use the IV pole as a walking aid	Walker, cane, wheelchair
3	Walking only in socks	Socks reduce grip on the hospital floor	Slippery or wet floor	Slips and falls	Use non-slip socks or appropriate footwear	Non-slip socks
4	Using inappropriate slippers	Slippers fold, slip off the foot, or have worn soles	Inadequate footwear	Trips and loss of balance	Prefer closed-toe shoes with non-slip soles	Hospital footwear
5	Reaching for distant objects	The patient leans excessively over the bed	Limited mobility, loss of center of gravity	Fall from bed	Keep frequently used objects within reach	Overbed table, bed organizers
6	Walking on a wet floor	The patient crosses a wet area during ambulation	Cleaning, leaks, or spills	Slips	Signal and immediately dry the floor	Warning signs
7	Bed-to-chair transfer	The chair moves or the patient loses stability during transfer	Unlocked brakes, lack of assistance, and muscle weakness	Fall during mobilization	Lock brakes and perform assisted transfer	Wheelchair, transfer belt
8	Getting up immediately after surgery or sedation	The patient tries to walk before adequate recovery	Anesthesia, opioids, hypotension, and dizziness	Fall and worsening of clinical condition	Assess clinical condition before ambulation	Walker, wheelchair
9	Child trying to get out of bed	The child tries to climb down alone or play on the bed	Curiosity, lack of supervision, and lowered bed rails	Fall from bed	Continuous supervision and raised bed rails when indicated	Hospital crib, side rails
10	Companion sleeping in the same bed as the child	The movement of the adult or child reduces stability during sleep	Bed sharing and lowered bed rails	Child's fall	Use the armchair or bed designated for the companion	Companion's armchair

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Table 2 – Factors that contribute most to falls

Observed factor	Frequency in analyzed situations	Impact level
Getting up without assistance	Very frequent	🔴 Very High
Changes in clinical state (weakness, dizziness, hypotension)	Very frequent	🔴 Very High
Inadequate environment	Frequent	🟠 High
Incorrect use of equipment	Frequent	🟠 High
Lack of patient education	Frequent	🟠 High
Lack of supervision	Frequent	🟠 High
Inappropriate footwear	Moderate	🟡 Medium
Objects out of reach	Moderate	🟡 Medium

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Table 3 – Responsibilities in prevention

Situation	Patient	Companion	Nursing	Doctor	Physiotherapist
Getting up without assistance	✔	✔	✔
Using an IV pole for support	✔		✔		✔
Walking only in socks	✔	✔	✔
Using inappropriate slippers	✔	✔	✔
Objects out of reach		✔	✔
Wet floor			✔
Bed-to-chair transfer			✔		✔
Immediate postoperative period			✔	✔	✔
Unsupervised child		✔	✔
Bed sharing		✔	✔

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Table 4 – Recommended conduct

Situation	What to do	What to avoid
Getting out of bed	Request assistance from the team	Getting up quickly or alone
Walking	Use appropriate footwear and a support device when indicated	Walking only in socks or loose slippers
Transfers	Lock brakes and perform movement with assistance	Moving the chair during transfer
Use of equipment	Only use equipment designed for walking support	Leaning on an IV pole or unstable furniture
Personal items	Keep call bell, phone, water, and glasses within reach	Leaning over to reach distant objects
Hospitalized children	Maintain constant supervision and raised bed rails when indicated	Allow the child to be unsupervised or share the bed

Dental Access Alert: Most hospital falls occur during routine and predictable activities. This means that a large part of these events can be avoided through simple measures, care planning, and active participation of the patient, companion, and multidisciplinary team.

Chapter Summary: Hospital falls are not random events. They occur in recurrent, identifiable, and, in most cases, preventable situations. Knowing these situations allows for directing preventive actions before an accident occurs. The tables presented in this chapter serve as a quick reference guide, helping healthcare professionals, managers, patients, and companions to recognize high-risk scenarios and adopt preventive measures objectively.

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Chapter 3 – Risk Factors for Falls in a Hospital Environment

Not all patients have the same risk of falling. While some can walk safely, others require constant supervision, support devices, or assistance from the team to perform simple activities.

Risk assessment should be performed upon patient admission and repeated whenever there are changes in their clinical condition, medication treatment, mobility, or hospitalization environment.

Risk factors can be classified as intrinsic, related to the patient's own conditions, and extrinsic, associated with the environment, equipment, and care process.

Table 1 – Classification of risk factors

Category	Definition	Examples
Intrinsic	Related to the patient's clinical and functional conditions	Advanced age, muscle weakness, cognitive impairment, hypotension, visual deficit
Extrinsic	Related to the environment, equipment, or care	Wet floor, inadequate lighting, lowered bed rails, chair without brakes, obstacles

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Table 2 – Main intrinsic risk factors

Factor	How it increases risk	Impact level
Advanced age	Reduced balance, muscle strength, and reflexes	🔴 Very High
History of falls	Indicates higher probability of recurrence	🔴 Very High
Gait disturbances	Instability during ambulation	🔴 Very High
Muscle weakness	Makes it difficult to get up and walk	🔴 Very High
Dizziness or vertigo	Compromises balance	🔴 Very High
Orthostatic hypotension	Can cause sudden loss of stability	🔴 Very High
Visual deficit	Makes it difficult to identify obstacles	🟠 High
Hearing deficit	Reduces environmental perception	🟡 Moderate
Cognitive impairment	Confusion, disorientation, and impulsivity	🔴 Very High
Parkinson's disease	Gait and balance disturbances	🔴 Very High
Stroke	Motor and sensory deficits	🔴 Very High
Severe pain	Limits safe movements	🟠 High
Urinary incontinence	Increases urgency to reach the bathroom	🟠 High

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Table 3 – Medications frequently associated with increased fall risk

Medication class	Possible effects	Risk level
Sedatives and hypnotics	Drowsiness and reduced reflexes	🔴 Very High
Benzodiazepines	Impaired balance and coordination	🔴 Very High
Opioids	Sedation, dizziness, and hypotension	🔴 Very High
Antihypertensives	Orthostatic hypotension	🔴 Very High
Diuretics	Urinary urgency and dehydration	🟠 High
Antidepressants	Changes in attention and balance	🟠 High
Antipsychotics	Sedation and motor disturbances	🔴 Very High
Hypoglycemics and insulin	Episodes of hypoglycemia	🟠 High

Important: The use of these medications does not contraindicate ambulation, but requires additional monitoring and preventive measures.

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Table 4 – Environmental factors

Situation found	How it contributes to a fall	Correction priority
Wet floor	Slipping	🔴 Immediate
Uneven floor	Tripping	🔴 Immediate
Insufficient lighting	Makes it difficult to see obstacles	🟠 High
Exposed cables and wires	Obstacles during walking	🟠 High
Scattered objects	Increase the risk of tripping	🟠 High
Lowered bed rails	Promote falls from bed	🔴 Immediate

Wheelchair without brakes Instability during transfer 🔴 Immediate Call bell out of reach Encourages patient to get up alone 🟠 High

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Table 5 – Patients requiring special attention

Patient profile	Justification	Recommended monitoring
Elderly	Natural reduction in functional capacity	Daily assessment
Immediate post-operative	Residual effect of anesthesia and analgesia	Assistance with first ambulation
Sedated patients	Reduced reflexes	Continuous supervision
Neurological deficit	Motor and cognitive changes	Individual mobilization plan
Patients with invasive devices	Mobility limitation	Assistance during movement
Young children	Curiosity and unpredictability	Constant supervision
Pregnant and postpartum women	Physiological changes and fatigue	Assistance when necessary

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Table 6 – Warning signs requiring immediate reassessment

Observed situation	Recommended action
Dizziness when standing up	Suspend ambulation and reassess
Recent fall	Reclassify risk and investigate cause
Change in level of consciousness	Immediately inform the medical team
Initiation of sedative medication	Reassess the prevention plan
Worsening mobility	Request physical therapy assessment
Episodes of hypotension	Monitor vital signs and review conduct
Agitation or mental confusion	Intensify supervision

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Myths and Facts

Statement	Answer	Comment
Only elderly people fall.	❌ Myth	Any patient can fall, depending on the circumstances.
Someone who has fallen before has a higher risk of falling again.	✅ Fact	A history of falls is an important predictive factor.
The use of sedatives increases the risk of falls.	✅ Fact	These medications can reduce reflexes and alter balance.
Independent patients do not need guidance.	❌ Myth	Guidance should be offered to all patients.
The risk of falling can change during hospitalization.	✅ Fact	Clinical or therapeutic changes require a new assessment.

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Checklist – Initial Fall Risk Assessment

Before defining preventive measures, check:

Item	Yes	No
History of falls in the last 12 months	☐	☐
Difficulty walking	☐	☐
Use of sedatives or opioids	☐	☐
Cognitive changes	☐	☐
Postural hypotension	☐	☐
Significant visual deficit	☐	☐
Need for mobility assistance	☐	☐
Use of support devices	☐	☐
Environment presents obstacles	☐	☐
Call bell and objects are within reach	☐	☐

Dental Access Alert: Fall risk is dynamic. A patient initially classified as low risk may become high risk after surgery, introduction of a new medication, clinical deterioration, or change in mobility. Therefore, assessment must be continuous throughout hospitalization.

Chapter Summary: Early identification of risk factors is the foundation of any fall prevention program. Assessing only the patient is not enough: it is also necessary to consider medications in use, the environment, available equipment, and how care is provided. The sooner these factors are recognized, the greater the chances of preventing an adverse event.

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Chapter 4 – Practical Measures for Fall Prevention

Fall prevention depends on the adoption of simple measures, systematically applied by the entire multidisciplinary team. After identifying risk factors, the next step is to implement interventions compatible with each patient's profile.

There is no single measure capable of completely eliminating the risk of falls. Success lies in combining different strategies involving the patient, companion, environment, equipment, and healthcare professionals.

Table 1 – Preventive measures according to risk factor

Identified factor	Preventive measure	Priority
Gait alteration	Assist ambulation and use support device when indicated	🔴 High
Postural hypotension	Help patient stand up gradually and monitor symptoms	🔴 High
Sedation	Restrict unassisted ambulation	🔴 High
Visual deficit	Ensure adequate lighting and use glasses when available	🟠 Medium
Cognitive deficit	Frequent supervision and repeated instructions	🔴 High
History of falls	Develop individual prevention plan	🔴 High
Muscle weakness	Request physical therapy assessment	🟠 Medium
Urinary urgency	Offer frequent assistance to go to the bathroom	🔴 High

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Table 2 – Hospital environment care

Item to check	Recommended condition
Floor	Clean, dry, and free of irregularities
Lighting	Adequate, especially at night
Corridors	Free of obstacles
Cables and wires	Organized and protected
Bed rails	Raised when indicated
Bed brakes	Locked during rest
Wheelchair brakes	Engaged during transfers
Personal belongings	Always within patient's reach
Call bell	Accessible at all times
Furniture	Positioned without hindering circulation

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Table 3 – Patient mobilization care

Situation	Recommended action
First ambulation after surgery	Always perform with team assistance
Bed-to-chair transfer	Lock brakes and instruct patient
Walking in the hallway	Assess need for companion or support device
Standing up after long period of rest	Sit on the edge of the bed first and observe for possible dizziness
Use of invasive devices	Organize cables and equipment before mobilization

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Table 4 – What should never happen

Inadequate conduct	Risk generated
Having the patient stand alone	Fall during mobilization
Using an IV pole as support	Equipment tipping over
Walking only in socks	Slipping
Using loose slippers	Tripping
Keeping bed rails down without indication	Fall from bed
Leaving the call bell out of reach	Patient attempts to get up alone
Leaving wet floor unmarked	Slips
Transferring patient without locking brakes	Instability of the chair or bed

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Table 5 – Multidisciplinary team responsibilities

Professional	Key preventive actions
Nurse	Assess risk, plan care, and educate patient and companion
Nursing Technician/Assistant	Execute preventive measures and monitor patient
Physician	Review medications and clinical conditions that increase risk
Physical Therapist	Assess gait, balance, and recommend assistive devices
Pharmacist	Identify medications associated with increased risk
Occupational Therapist	Propose adaptations for safe mobility
Housekeeping Team	Keep floors dry and signpost cleaning areas
Managers	Ensure resources, training, and indicator monitoring

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Table 6 – Patient and companion participation

Patient should...	Companion should...
Ask for help before getting up	Call the team when noticing mobility difficulty
Wear appropriate footwear	Do not get up or transfer the patient alone
Report episodes of dizziness	Keep bed rails according to team guidance
Use prescribed devices	Keep personal belongings organized and within reach
Respect team instructions	Report any observed changes in the patient

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Operational prevention flow

Inpatient
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Risk assessment
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Identification of risk factors
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Definition of preventive measures
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Patient and companion education
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Environment adaptation
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Continuous monitoring
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Reassessment whenever there is a clinical change

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The equipment used in fall prevention, its indications, and best practices are detailed in Chapter 7.

Dental Access Alert: Fall prevention does not depend solely on equipment or protocols. It primarily depends on the consistent application of simple measures across all shifts. Small failures, when combined, can result in a serious adverse event.

Chapter Summary: Fall prevention should be viewed as a continuous process, initiated upon patient admission and maintained throughout hospitalization. Systematic assessment of risk factors, environmental adaptation, correct use of equipment, and active participation of the team, patient, and companion form a set of actions capable of significantly reducing the occurrence of falls and promoting safer care.

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Chapter 5 – Special Care in Fall Prevention

Although the principles of fall prevention are the same for all patients, some groups have clinical characteristics that require specific care.

The elderly, children, pregnant women, critically ill patients, and people with cognitive changes, for example, have their own risk factors and require individualized strategies to reduce the occurrence of accidents.

Table 1 – Care by patient profile

Profile	Main risks	Priority measures
Elderly	Loss of balance, muscle weakness, visual changes, and use of multiple medications	Assistance with ambulation, adequate lighting, support devices, and frequent reassessment
Children	Curiosity, impulsivity, and difficulty recognizing risks	Constant supervision, raised bed rails when indicated, and guidance to caregivers
Pregnant and postpartum women	Balance changes, hypotension, fatigue, and pain	Assistance with first ambulation and support for bathroom visits
Post-operative	Residual sedation, pain, and hypotension	Assisted first mobilization and continuous monitoring
Neurological patients	Motor, sensory, and cognitive deficits	Individual mobilization plan and physical therapy
Critically ill patients	Invasive devices, acquired weakness, and clinical instability	Mobilization planned by the multidisciplinary team

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1. Elderly

The elderly represent one of the groups with the highest incidence of hospital falls due to physiological changes related to aging and the higher frequency of chronic diseases.

Condition	How it interferes
Reduced muscle strength	Makes standing and walking difficult
Visual changes	Make identifying obstacles difficult
Auditory changes	Reduce perception of the environment
Osteoporosis	Increases fracture risk
Polypharmacy	Can cause dizziness, drowsiness, and hypotension
Neurological diseases	Alter balance and coordination

Recommendations:

• Always assist with the first ambulation.
• Avoid abrupt changes in position.
• Encourage the use of prescribed assistive devices.
• Reassess risk daily.

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2. Children

Falls in pediatrics are generally not related to loss of balance, but to the child's exploratory behavior.

Situation	Risk
Child trying to climb out of crib	Very High
Playing on the bed	High
Bed rails down	Very High
Inadequate supervision	Very High

Recommendations:

• Maintain continuous supervision.
• Use age-appropriate cribs and beds.
• Keep bed rails up when indicated.
• Educate parents and guardians.

Table 2 – Recommendations for guardians of children

Do	Avoid
Ask nursing staff for help to remove the child from the bed	Leaving the child alone in bed
Use the armchair provided for the guardian	Sleeping with the child in the same bed
Keep toys organized	Leaving objects scattered in the room
Report any clinical changes	Moving the child without guidance when there are restrictions

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3. Pregnant and Postpartum Women

During pregnancy, and especially in the immediate postpartum period, physiological changes can temporarily compromise balance and mobility.

Situation	Possible consequence
Hypotension	Dizziness when standing up
Postoperative pain	Gait instability
Fatigue	Reduced reflexes
Bleeding	Weakness
Use of analgesics	Drowsiness

Recommendations:

• Assist with the first ambulation.
• Offer support when going to the bathroom.
• Provide guidance on using the call bell.
• Avoid standing up quickly.

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4. Neurological Patients

Patients with stroke, Parkinson's disease, multiple sclerosis, or other neurological conditions experience significant changes in mobility.

Situation	Action
Hemiparesis	Bilateral assistance during ambulation
Balance impairment	Assistive device as per assessment
Cognitive deficit	Constant supervision
Visual impairment	Environment adaptation

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5. Postoperative Patients

The period immediately following surgery carries a high risk of falls due to the residual effects of anesthesia, analgesia, and a temporary reduction in functional capacity.

Check	OK
Stable vital signs	☐
Patient conscious	☐
No significant dizziness	☐
Adequate analgesia	☐
Team available to assist	☐
Appropriate footwear	☐
Environment free of obstacles	☐

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6. Patients with Cognitive Impairment

Patients with dementia, delirium, or other cognitive impairments often do not recognize their own functional limitations.

Measure	Goal
Frequent supervision	Prevent unassisted mobilization
Verbal reorientation	Reduce disorientation
Organized environment	Reduce stimuli that favor impulsivity
Family involvement	Reinforce safety guidelines

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Table 3 – Specific measures by profile

Preventive measure	Elderly	Children	Pregnant Women	Neurological	Postoperative
Daily assessment	✔	✔	✔	✔	✔
Ambulation supervision	✔	✔	✔	✔	✔
Bed rails up when indicated	✔	✔		✔	✔
Support device	✔			✔	✔
Guidance to companion	✔	✔	✔	✔	✔
Reassessment after clinical change	✔	✔	✔	✔	✔

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Special Attention – Situations requiring reinforced vigilance

Situation	Reason
First 24 hours after surgery	Residual effects of anesthesia and analgesia
Introduction of sedatives	Altered level of consciousness
Episodes of hypotension	Instability upon standing
Delirium or mental confusion	Unpredictable behavior
First mobilization after a long period in bed	Muscle weakness and orthostatic intolerance
Unsupervised children	Exploratory behavior

Dental Access Alert: Fall prevention protocols must be adapted to the needs of each patient. Applying the same measures to all profiles may be insufficient or, in some cases, inappropriate. Individualizing care is one of the pillars of patient safety.

Chapter Summary: Hospitalized patients have distinct needs based on age, clinical condition, treatment received, and functional capacity. Recognizing these particularities allows the multidisciplinary team to adopt specific preventive measures, reducing the incidence of falls and promoting safer and more personalized care.

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Chapter 6 – Fall Prevention by Hospital Environment

The risk of falls varies according to the hospital environment. Each sector has its own characteristics related to patient profiles, procedures performed, equipment used, and care dynamics.

For this reason, preventive measures must be adapted to the specificities of each location, reducing the specific risks of each stage of care.

Table 1 – Main hospital environments and their risks

Environment	Risk level	Main causes of falls
Inpatient room	🔴 Very High	Getting up alone, bed rails down, objects out of reach
Bathroom	🔴 Very High	Wet floor, insufficient grab bars, dizziness
Corridors	🟠 High	Unassisted walking, obstacles, slippery floors
Surgical Center	🟡 Moderate	Transfers and anesthetic movement
Post-Anesthesia Care Unit	🔴 Very High	Drowsiness, hypotension, and effects of anesthesia
ICU	🟠 High	Mobilization with multiple invasive devices
Pediatrics	🔴 Very High	Children trying to get out of bed
Obstetrics	🟠 High	Hypotension, pain, and postpartum fatigue
Diagnostic imaging	🟠 High	Transfers between stretcher and equipment
Intra-hospital transport	🔴 Very High	Displacements and changes in surface

---

1. Inpatient Room

Most hospital falls occur within the patient's room, primarily during routine activities.

Situation	Risk
Getting up without assistance	🔴 Very High
Objects out of reach	🟠 High
Bed rails down	🔴 Very High
Insufficient lighting	🟠 High
Cables crossing pathways	🟠 High

Room Checklist

Item	Check
Call bell accessible	☐
Water within reach	☐
Cellphone and glasses nearby	☐
Bed rails as indicated	☐
Bed brakes locked	☐
Floor dry	☐
Adequate night lighting	☐
Appropriate footwear	☐
Patient oriented	☐
Companion oriented	☐

---

2. Bathroom

The bathroom combines several risk factors simultaneously: wet floor, limited space, changes in position, and momentary absence of staff.

Situation	Consequence
Wet floor	Slipping
Standing up from the toilet	Postural hypotension
Lack of grab bars	Loss of balance
Improvised rugs	Tripping

Do	Avoid
Use grab bars	Leaning on doors or sinks
Ask for help when needed	Going to the bathroom alone even with dizziness
Keep the floor dry	Leaving water accumulated

---

3. Corridors

Although they are wide areas, corridors concentrate falls related to ambulation.

Factor	Preventive measure
Waxed floor	Use products that do not leave a slippery surface
Stationed equipment	Keep pathways clear
Cables and extensions	Organize properly
Insufficient lighting	Correct immediately

---

4. Surgical Center and Anesthesia Recovery

In this sector, the main concern is early mobilization after anesthetic procedures.

Situation	Conduct
First ambulation	Always assisted
Stretcher-to-bed transfer	Sufficient team for mobilization
Drowsiness	Do not allow independent ambulation
Hypotension	Monitor before mobilization

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5. Intensive Care Unit (ICU)

Even bedridden patients can suffer falls during mobilization or transfer procedures.

Situation	Risk
Early mobilization	Clinical instability
Multiple devices	Tangled cables and equipment
Transfer for exams	Disconnections and loss of stability

Recommendations:

• Plan all mobilization.
• Pre-organize devices.
• Define roles for each team member.
• Confirm locking of beds and stretchers.

---

6. Pediatrics

Falls in pediatrics have their own characteristics.

Situation	Preventive measure
Child playing on the bed	Constant supervision
Bed rails down	Keep elevated when indicated
Scattered toys	Environmental organization
Unaccompanied child	Never leave unsupervised

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7. Obstetrics

After childbirth, especially C-sections, the patient may experience significant temporary limitations.

Situation	Conduct
First ambulation	Assisted by the team
Bathing	Assistance when necessary
Transporting the newborn	Avoid carrying the baby during episodes of dizziness
Intense pain	Reassess before mobilization

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8. Intra-hospital Transport

Movement between sectors represents a moment of high risk, especially for patients with reduced mobility.

Item	OK
Identification confirmed	☐
Brakes checked	☐
Bed rails up when indicated	☐
Devices organized	☐
Oxygen cylinder secured	☐
Patient oriented	☐

---

Table 2 – Recommended equipment by environment

Environment	Most used equipment
Room	Hospital bed, side rails, call bell
Bathroom	Grab bars, commode chair
Corridors	Handrails and signage
Surgical Center	Stretchers with restraints and safety belts
Anesthetic Recovery	Stretchers with side rails
ICU	Electric hospital bed, mobilization devices
Pediatrics	Hospital cribs and rails
Obstetrics	Breastfeeding armchairs and grab bars
Transport	Stretchers, wheelchairs and safety belts

---

Table 3 – Quick audit by environment

Question	Yes	No
Is the environment free of obstacles?	☐	☐
Is the floor dry?	☐	☐
Is the lighting sufficient?	☐	☐
Is the equipment in good condition?	☐	☐
Are the brakes working?	☐	☐
Are grab bars present where needed?	☐	☐
Is there adequate signage?	☐	☐
Do staff know the protocol?	☐	☐

Dental Access Alert: Patient safety depends not only on assessing who might fall, but also on identifying where falls tend to happen. An organized, well-marked, and equipped environment significantly reduces the likelihood of accidents and complements clinical prevention measures.

Chapter Summary: Each hospital environment presents specific risks that require its own preventive strategies. The adequacy of the physical space, the availability of appropriate equipment, the organization of the care flow, and the integrated action of the team are fundamental to reducing the occurrence of falls in all sectors of the institution.

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Chapter 7 – Equipment Used in Fall Prevention

Fall prevention depends on a combination of clinical assessment, staff training, environmental organization, and proper use of support equipment.

Each piece of equipment has a specific purpose and should be selected according to the patient's needs, degree of mobility, risk of falling, and care environment. Similarly, improper use can create new risks and compromise patient safety.

Important: No equipment replaces the supervision of the healthcare team or the measures provided for in the institutional fall prevention protocol.

Table 1 – Equipment used in fall prevention

Equipment	Purpose	Main indications	Good practices	Errors to avoid	Classification
Hospital bed	Ensure rest and facilitate safe mobilization	All hospitalized patients	Keep brakes applied, adjust height before transfers, and keep call bell and objects within reach	Bed elevated or unlocked during transfer	🔴
Side rails	Reduce the risk of falling out of bed when clinically indicated	Sedated, confused, pediatric patients or those at high risk	Assess need daily and position correctly	Use as physical restraint without indication or keep them lowered when needed	🔴
Grab bars	Aid changes in position and balance	Bathrooms, corridors, and circulation areas	Check fixation and instruct patient on use	Leaning on doors, sinks, or furniture	🔴
Wheelchair	Ensure safe transport	Patients with reduced mobility	Lock brakes before transfers and remove footrests when necessary	Transferring the patient with the chair unlocked	🔴
Walker	Increase stability during ambulation	Patients with balance deficit	Adjust height and instruct on correct walking technique	Walking far from the equipment or using it improperly adjusted	🔴
Cane	Provide partial support during ambulation	Patients with mild mobility limitation	Adjust height correctly and check non-slip tip	Use with worn tip or inadequate height	🟠
Crutches	Reduce load on one or both lower limbs	Orthopedic and post-operative patients	Adjust correctly and instruct on walking sequence	Bearing weight on armpits or using incorrect adjustment	🟠
Non-slip socks	Improve floor grip	Patients ambulating in the hospital environment	Use appropriate size and replace when worn	Use regular socks on slippery floors	🟠
Hospital footwear	Reduce slips and trips	Patients in the process of mobilization	Use closed models with non-slip soles	Use loose slippers or worn footwear	🟠
Commode chair	Reduce trips to the bathroom	Dependent patients or those with limited mobility	Lock brakes before use and position correctly	Moving the chair during transfer	🟠
Transfer belt	Provide greater control during mobilization	Dependent patients or those with instability	Use only by trained professionals and adjust correctly to the patient	Pulling the patient by the arms or clothes	🟠

Legend

Symbol	Classification
🔴	Essential equipment in fall prevention
🟠	Complementary equipment, used according to clinical evaluation
🟡	Equipment indicated for specific situations

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Table 2 – How to choose the right equipment

Clinical situation	Most suitable equipment
Patient confined to bed	Hospital bed, side rails
Mild balance deficit	Cane
Moderate gait deficit	Walker
Inability to ambulate safely	Wheelchair
Difficulty using the bathroom	Grab bars and commode chair
Frequent transfers	Transfer belt
Immediate post-operative	Hospital bed, wheelchair, walker (when indicated)
Pediatric patient	Hospital crib or bed with rails as per assessment

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Table 3 – Checklist before use

Verification	✔
Equipment intact and without apparent damage	☐
Brakes working correctly (when applicable)	☐
Wheels in good condition	☐
Appropriate adjustment for the patient	☐
Non-slip tips intact	☐
Firm and stable structure	☐
Cleaning and disinfection performed according to protocol	☐
Patient instructed on use	☐

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Table 4 – Good practices in equipment use

Equipment	Good practices
Hospital bed	Adjust height before transfers and keep brakes applied
Side rails	Use only when clinically indicated and check locking mechanism
Wheelchair	Lock brakes and remove footrests before transfer
Walker	Walk keeping the equipment close to the body
Cane	Always use with tip in good condition
Grab bars	Encourage the patient to use them during position changes
Transfer belt	Position correctly and use appropriate mobilization technique

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Table 5 – Most frequent errors

Situation	Consequence
Bed brakes unlocked	Displacement during transfer
Wheelchair brakes unlocked	Fall while sitting or standing
Walker with incorrect height	Alteration of posture and loss of balance
Cane with worn tip	Slipping
Loose grab bars	Structural failure during support
Regular socks on slippery floor	Slips
Slippers without fastening	Trips
Transfer belt used incorrectly	Loss of mobilization control

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Table 6 – Inspection and preventive maintenance

Equipment	What to check	Recommended frequency*
Hospital bed	Brakes, wheels, controls, rails, and structure	Before each use and according to institutional plan
Wheelchair	Brakes, tires, wheels, supports, and structure	Before each use
Walker	Structure, adjustment, and tips	Before each use
Cane	Adjustment and tip	Before each use
Grab bars	Fixation and structural integrity	According to building maintenance plan
Commode chair	Structure, wheels, and brakes	Before each use
Transfer belt	Seams, fasteners, and material integrity	Before each use

*The inspection frequency must follow the institution's preventive maintenance plan, manufacturer's recommendations, and internal protocols.

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Flowchart – Equipment selection

Patient assessed
        │
        ▼
Is there a risk of falling?
        │
   ┌────┴────┐
   │         │
  No        Yes
   │         │
General    Assess mobility
care         │
               ▼
     Confined to bed?
          │         │
         Yes       No
          │         │
 Bed + Rails   Assess gait
                     │
      ┌──────────────┼──────────────┐
      │              │              │
 Mild support    Moderate support   Unable to ambulate safely
      │              │              │
  Cane        Walker     Wheelchair

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Recommendations for equipment acquisition

When selecting equipment for fall prevention, the institution should consider:

• Compliance with applicable sanitary legislation.
• Regular registration when required.
• Instructions for Use (IFU) provided by the manufacturer.
• Ease of cleaning and disinfection.
• Ergonomics for patients and professionals.
• Availability of spare parts and technical assistance.
• User training.
• Compatibility with the institution's care profile.

Dental Access Alert: The effectiveness of equipment depends directly on three factors: adequate selection, correct use, and preventive maintenance. Safe equipment, combined with trained professionals and well-defined protocols, significantly reduces the risk of falls and contributes to safer care.

Chapter Summary: Equipment for fall prevention plays a fundamental role in patient safety, provided it is selected according to clinical condition, used correctly, and maintained in perfect working order. Adopting good practices, periodic inspections, and continuous team training reduces operational failures and strengthens the culture of safety in healthcare institutions.

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Chapter 8 – Fall Risk Assessment

Fall risk assessment is one of the first safety measures that should be performed upon patient admission and repeated whenever there are changes in their clinical condition.

The objective is not only to classify the patient as low, moderate, or high risk, but to direct preventive measures proportional to their clinical profile.

Important: Risk assessment should be integrated into the care plan and re-evaluated whenever there are significant changes in the patient's condition, such as surgeries, initiation of high-risk medications, or changes in mobility.

Table 1 – When to assess fall risk

Time of care	Recommended assessment	Objective
Admission	✔	Identify initial risks
Transfer between sectors	✔	Check clinical changes
Post-operative	✔	Identify risks arising from anesthesia and surgery
Significant change in clinical status	✔	Update the preventive plan
Introduction of high-risk medications	✔	Re-evaluate drug-related risk
After a fall	✔	Review contributing factors and reinforce preventive measures
Hospital discharge	When indicated	Guide continuity of care

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Table 2 – Main factors assessed

Factor What should be observed History of falls Previous falls significantly increase risk Mobility Gait, balance, need for assistance Cognitive status Confusion, delirium, dementia, or disorientation Medication use Sedatives, opioids, antihypertensives, diuretics, among others Vision and hearing Deficits that hinder perception of the environment Incontinence Urinary urgency or frequent need to go to the bathroom Invasive devices Probes, drains, catheters, and equipment that limit mobility Environment Obstacles, lighting, and room organization

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Table 3 – Main scales used

Scale	Target audience	Application	Advantages	Limitations
Morse Fall Scale	Hospitalized adults	General hospitals	Quick application and widely used	Not specific for pediatrics
STRATIFY	Adults and elderly	Wards	Simple and objective	Less comprehensive range of factors
Humpty Dumpty	Pediatrics	Children's hospitals	Developed for children	Not applicable to adults
Johns Hopkins Fall Risk Assessment Tool	Adults	Medium and high complexity hospitals	Comprehensive assessment	Requires more application time

Note: Each institution must use the scale defined in its internal protocol, respecting the recommendations of the Patient Safety Committee and the characteristics of the care profile.

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Table 4 – Comparison of scales

Criterion	Morse	STRATIFY	Humpty Dumpty	Johns Hopkins
Adults	✔	✔	✖	✔
Pediatrics	✖	✖	✔	✖
Quick application	✔	✔	✔	◐
Gait assessment	✔	✔	✔	✔
Medication assessment	Partial	Partial	Partial	✔
Use in Brazilian hospitals	Very frequent	Frequent	Frequent in pediatrics	Growing

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Table 5 – Practical interpretation of the assessment

Assessment result	Recommended actions
Low risk	General safety guidelines, environment organization, and routine monitoring
Moderate risk	Reinforce guidelines, review environment, assess need for support devices, and increase supervision
High risk	Implement all preventive measures foreseen in the institutional protocol, reinforce patient identification, instruct escort, and intensify surveillance

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Flowchart – Fall risk assessment

Patient admitted
        │
        ▼
Initial assessment
        │
        ▼
Application of the institutional scale
        │
        ▼
Risk classification
        │
 ┌──────┼─────────┐
 │      │         │
Low   Moderate High
 │      │         │
 ▼      ▼         ▼
Basic  Expanded   Intensive
measures measures   preventive measures
        │
        ▼
Periodic reassessment

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Table 6 – Signs that require immediate reassessment

Situation	Reassess?
Fall during hospitalization	✔
Surgery performed	✔
Introduction of sedatives or opioids	✔
Change in level of consciousness	✔
Significant change in mobility	✔
Episodes of dizziness or syncope	✔
Hypotension	✔
Change of sector	✔

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Checklist – Patient's initial assessment

Item	✔
History of falls investigated	☐
Gait and balance assessed	☐
Cognitive status assessed	☐
Medications reviewed	☐
Need for ambulation assistance identified	☐
Environment inspected	☐
Escort instructed (when applicable)	☐
Preventive plan recorded	☐

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Table 7 – Most common errors during assessment

Error	Possible consequence
Assess only upon admission	Clinical changes go undetected
Do not record risk classification	Communication failures between teams
Do not reassess after surgery or intercurrent events	Preventive measures become inadequate
Disregard newly prescribed medications	Unidentified increased risk
Do not involve the escort	Lower adherence to preventive measures

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Best practices for implementing risk assessment

• Define a single institutional scale.
• Train the entire team for its application.
• Record the result in the medical record.
• Integrate the classification into the care plan.
• Reassess the patient whenever there is a clinical change.
• Use the assessment as a decision-making tool, not just as a documentary requirement.
• Monitor indicators to verify the effectiveness of the protocol.

Dental Access Alert: Fall risk assessment should be understood as a continuous process. A patient's risk may change throughout hospitalization, making periodic reassessments and updating of preventive measures essential according to their clinical evolution.

Chapter Summary: Systematic fall risk assessment allows for early identification of more vulnerable patients and guides interventions proportional to their needs. When integrated into institutional protocols, adequately documented, and reviewed throughout hospitalization, it strengthens the patient safety culture and reduces the occurrence of adverse events.

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Chapter 9 – Fall Risk Signaling and Communication

Visual identification and effective communication among professionals are essential components of fall prevention programs.

After risk assessment, information must be transmitted clearly and standardly to everyone involved in care, reducing communication failures and allowing for the immediate adoption of preventive measures.

Important: Signaling methods may vary between institutions. The most important thing is that the system is standardized, widely known by the team, and integrated into internal protocols.

Table 1 – Objectives of fall risk signaling

Objective	Benefit for care
Quickly identify at-risk patients	Agility in adopting preventive measures
Alert the entire multiprofessional team	Reduction of communication failures
Facilitate continuity of care	Safety during shift changes and transfers
Involve patients and escorts	Greater adherence to guidelines
Standardize institutional processes	Uniformity of conduct

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Table 2 – Main forms of signaling

Method	Where it is used	Best practices	Cautions
Identification bracelet	Patient's wrist	Use according to institutional protocol	Periodically confirm its presence and integrity
Bedside plaque	Bed headboard	Use a symbol standardized by the institution	Avoid excessive information
Identification in the medical record	Physical or electronic record	Update whenever there is a reassessment	Ensure complete record
Alert in the electronic system	Electronic medical record	Make information available to all teams	Review after clinical changes
Signaling in the room	Door or internal panel (when adopted)	Use according to institutional norms	Preserve patient privacy

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Table 3 – Situations requiring immediate signaling update

Situation	Update signaling?
Change in risk classification	✔
Post-operative	✔
Introduction of sedatives or opioids	✔
Cognitive alteration	✔
Fall episode	✔
Transfer to another sector	✔
Hospital discharge	Remove according to protocol

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Flowchart – Risk communication

Assessment performed
        │
        ▼
Risk classification
        │
        ▼
Record in the medical record
        │
        ▼
Application of institutional signaling
        │
        ▼
Communication to the multiprofessional team
        │
        ▼
Guidance to patient and escort
        │
        ▼
Periodic reassessment

---

Table 4 – Communication during shift handover

Information	Should it be communicated?
Risk classification	✔
Previous falls	✔
Recent mobility changes	✔
Need for ambulation assistance	✔
Use of support equipment	✔
Presence of escort	✔
Preventive measures in progress	✔

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Table 5 – Patient instructions

Instruction	Objective
Request assistance before getting up	Avoid unsupervised mobilization
Use the call bell when necessary	Facilitate team assistance
Wear appropriate footwear	Reduce slips
Do not use the IV pole as walking support	Avoid loss of balance
Report episodes of dizziness or weakness	Allow clinical reassessment

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Table 6 – Instructions for the escort

Instruction	Reason
Do not lift the patient alone	Avoid accidents during mobilization
Request team assistance whenever necessary	Ensure safe transfer
Keep objects organized	Reduce obstacles
Report changes in clinical condition	Update the preventive plan
Respect team instructions	Ensure uniformity of conduct

---

Table 7 – Most frequent errors in communication

Error	Consequence
Do not record risk assessment	Failures in continuity of care
Do not update signaling after reassessment	Inadequate preventive measures
Incomplete information in shift handover	Loss of important information
Do not instruct the escort	Reduced adherence to preventive measures
Different identification systems between sectors	Confusion and increased risk of failures

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Checklist – Risk communication audit

Item	✔
Assessment recorded in the medical record	☐
Signaling applied according to protocol	☐
Team instructed	☐
Patient instructed	☐
Escort instructed (when applicable)	☐
Information passed on in shift handover	☐
Reassessment recorded	☐

---

Good institutional practices

To strengthen fall risk communication, it is recommended that the institution:

• Adopt a single identification standard for all sectors.
• Continuously train professionals on the meaning of the signaling used.
• Integrate risk classification into electronic and printed systems.
• Establish routines for updating signaling whenever there are clinical changes.
• Include fall risk classification as a mandatory item in shift handovers and transfers between sectors.
• Instruct patients and escorts in a standardized and documented manner.

Dental Access Alert: Visual identification of fall risk is not an end in itself. Its purpose is to ensure that any professional who comes into contact with the patient immediately recognizes the need for additional care and adopts the preventive measures foreseen in the institutional protocol.

Chapter Summary: Effective communication is the link between risk assessment and the implementation of preventive measures. Standardized signaling systems, updated records, structured shift handovers, and continuous instruction for patients and escorts reduce communication failures and strengthen the culture of safety in healthcare institutions.

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Chapter 10 – Conduct After a Fall Occurs

Even with well-established protocols, regular training, and adequate preventive measures, falls can still occur.

When this happens, the team's objective shifts from prevention to minimizing harm, early identification of injuries, immediate patient treatment, investigation of causes, and implementation of actions to prevent further occurrences.

Important: the patient should not be lifted immediately after a fall without an initial assessment, especially if there is suspicion of trauma, loss of consciousness, or complaint of severe pain.

Flowchart – Immediate conduct after a fall

Patient suffers a fall
          │
          ▼
Ensure scene safety
          │
          ▼
Assess level of consciousness
          │
          ▼
Check for signs of injury
          │
          ▼
Alert responsible team
          │
          ▼
Perform clinical assessment
          │
          ▼
Determine need for exams
          │
          ▼
Record the event
          │
          ▼
Report according to institutional protocol
          │
          ▼
Investigate causes
          │
          ▼
Review the prevention plan

---

Table 1 – Immediate actions

Step	Objective	Good practices	Avoid
Ensure safety	Prevent new accidents	Remove environmental hazards	Moving the patient without assessment
Initial assessment	Identify severity	Check consciousness, breathing, and complaints	Underestimating mild symptoms
Team activation	Ensure adequate care	Immediately notify the person in charge	Delaying communication
Clinical assessment	Identify injuries	Carefully examine the patient	Assuming no injuries just because the patient is conscious
Documentation	Ensure traceability	Document all findings	Incomplete records

---

Table 2 – Initial clinical assessment

Item	Check
State of consciousness	Alert, drowsy, or unconscious
Pain complaint	Location and intensity
Bleeding	Presence and origin
Deformities	Suspicion of fractures
Mobility	Ability to move limbs
Head trauma	Presence of impact or neurological signs
Vital signs	According to institutional protocol

---

Table 3 – Situations requiring immediate attention

Situation	Priority action
Loss of consciousness	Immediate medical assessment
Head trauma	Monitoring and investigation according to protocol
Suspicion of fracture	Immobilize when indicated and avoid unnecessary mobilization
Severe pain	Immediate clinical assessment
Significant bleeding	Initial control and immediate care
Neurological alteration	Urgent activation of the medical team

---

Table 4 – Event documentation

Information	Must be included in the record
Date and time	✔
Location of occurrence	✔
Circumstances of the fall	✔
Activity performed by the patient	✔
Professionals present	✔
Observed injuries	✔
Actions taken	✔
Communication with family (if applicable)	✔

---

Table 5 – Investigation of causes

Aspect analyzed	Examples
Patient factors	Dizziness, hypotension, cognitive alteration
Environmental factors	Wet floor, inadequate lighting
Equipment	Unlocked brakes, damaged rails
Care process	Failure in supervision or communication
Medications	Sedation or hypotension related to treatment

---

Table 6 – Corrective actions

Situation found	Recommended action
Wet floor	Correct immediately and revise cleaning routine
Failure in risk assessment	Re-evaluate all similar patients
Inadequate equipment	Replace or repair before new use
Communication failure	Reinforce training and shift handover
Non-use of preventive measures	Review protocol adherence

---

Table 7 – What NOT to do after a fall

Inadequate conduct	Why it should be avoided
Lifting the patient immediately	May worsen hidden injuries
Minimizing the occurrence due to absence of pain	Some injuries manifest later
Failing to document the event	Compromises investigation and traceability
Not communicating with the responsible team	Delay in care
Not reviewing the preventive plan	Favors recurrences

---

Checklist – Post-fall care

Item	✔
Safe environment	☐
Initial assessment performed	☐
Responsible team activated	☐
Injuries investigated	☐
Complete record made	☐
Institutional notification carried out	☐
Causes investigated	☐
Preventive plan updated	☐
Patient and companion oriented	☐

---

Institutional learning

Every fall should be analyzed as an opportunity for improvement. Regardless of severity, the institution is recommended to:

• Investigate immediate and contributing causes.
• Identify failures in care processes.
• Implement corrective and preventive actions.
• Share learnings with teams.
• Monitor indicators to assess the effectiveness of implemented improvements.

This approach strengthens the safety culture and reduces the likelihood of recurrence.

Dental Access Alert: Patient care after a fall does not end with the clinical assessment. Investigation of causes, process review, and implementation of improvements are fundamental steps to prevent new events and promote increasingly safe care.

Chapter Summary: A rapid, organized, and protocol-based response reduces harm to the patient and provides essential information for continuous improvement of care processes. In addition to clinical care, documentation, investigation, and review of preventive measures are indispensable components of an effective fall prevention program.

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Chapter 11 – Implementation and Monitoring of the Fall Prevention Protocol

Fall prevention does not depend solely on good intentions or committed professionals. It requires a structured protocol, systematically implemented, continuously monitored, and revised whenever necessary.

Institutions that adopt formal fall prevention programs show consistently better results than those that rely only on individual or informal initiatives.

Table 1 – Essential components of a fall prevention protocol

Component	Description	Responsible
Risk assessment	Application of validated scale upon admission and during reassessments	Nursing
Preventive measures	Interventions proportionate to identified risk	Multidisciplinary team
Signaling	Standardized identification of at-risk patients	Nursing
Orientation	Education of patients and companions	All staff
Documentation	Documentation of assessments and procedures	All staff
Reporting	Communication of adverse events	All staff
Investigation	Analysis of causes after each fall	Managers and care team
Monitoring	Tracking indicators	Managers and quality
Training	Continuous staff training	Managers and continuing education

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Table 2 – Steps for protocol implementation

Step	Action	Expected outcome
1	Situational diagnosis	Identify the current reality of the institution
2	Definition of assessment scale	Standardize the instrument used
3	Protocol elaboration	Document procedures and responsibilities
4	Staff training	Ensure knowledge and adherence
5	Pilot implementation	Test and adjust the protocol
6	Expanded implementation	Expand to all sectors
7	Indicator monitoring	Evaluate results and identify improvements
8	Periodic review	Keep the protocol updated

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Table 3 – Monitoring indicators

Indicator	What it measures	How to calculate
Fall rate	Frequency of falls in the period	Number of falls ÷ patient-days × 1,000
Fall with harm rate	Proportion of falls resulting in injury	Falls with harm ÷ total falls × 100
Risk assessment rate	Adherence to assessment upon admission	Patients assessed ÷ total admissions × 100
Reassessment rate	Frequency of reassessments performed	Reassessments performed ÷ expected reassessments × 100
Notification rate	Proportion of reported falls	Reported falls ÷ total falls × 100

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Table 4 – Factors favoring protocol adherence

Factor	How it contributes
Leadership support	Legitimizes the protocol and facilitates resource allocation
Continuous training	Keeps staff updated and engaged
Indicator feedback	Demonstrates results and motivates improvements
Integration into medical record	Facilitates documentation and communication
Multidisciplinary team participation	Broadens perspective on risk factors
Patient and companion involvement	Increases adherence to preventive measures

---

Table 5 – Most common barriers and how to overcome them

Barrier	Overcoming strategy
Lack of time for assessment	Simplify the instrument and integrate it into the care flow
Lack of protocol knowledge	Periodic training and accessible support materials
Low team adherence	Indicator feedback and involvement in decisions
Lack of equipment	Acquisition planning and preventive maintenance
Inefficient communication between shifts	Structure shift handover with a specific item for fall risk
Underreporting of events	Non-punitive safety culture and incentive for reporting

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Flowchart – Continuous improvement cycle

Protocol implementation
        │
        ▼
Indicator monitoring
        │
        ▼
Identification of failures
        │
        ▼
Analysis of causes
        │
        ▼
Implementation of improvements
        │
        ▼
Re-evaluation of results
        │
        ▼
Protocol review
        │
        ▼
(restart cycle)

---

Table 6 – Responsibilities by hierarchical level

Level	Responsibilities
Senior management	Approve the protocol, ensure resources, and promote a culture of safety
Care managers	Supervise implementation, monitor indicators, and support the team
Nurses	Assess risk, plan care, and guide the team
Technicians and assistants	Execute preventive measures and communicate changes
Physicians	Review medications and clinical risk conditions
Physical therapists	Assess mobility and indicate assistive devices
Pharmacists	Identify medications associated with risk
Quality team	Monitor indicators and support investigations

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Checklist – Protocol Implementation

Item	✔
Situational diagnosis performed	☐
Assessment scale defined	☐
Protocol developed and approved	☐
Team trained	☐
Signage materials available	☐
Indicators defined	☐
Notification system implemented	☐
Monitoring initiated	☐
Periodic review scheduled	☐

Dental Access Alert: A well-designed but underutilized protocol does not protect the patient. The effectiveness of a fall prevention program depends on the consistent adherence of the entire team, continuous monitoring of results, and institutional willingness to learn from mistakes and implement improvements.

Chapter Summary: Implementing a formal fall prevention protocol is the most important step to transform good individual practices into an institutional culture of safety. Continuous monitoring of indicators, team training, and leadership commitment are the pillars that support effective and lasting programs.

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Conclusion

Fall prevention in a hospital environment is a shared responsibility. There is no single measure capable of completely eliminating this risk, but the combination of systematic assessment, proportionate preventive measures, an appropriate environment, correct equipment, effective communication, and active participation from patients and companions significantly reduces the occurrence of adverse events.

Throughout this guide, we have covered the main aspects involved in fall prevention: from understanding how accidents happen in practice to implementing and monitoring institutional protocols. Each chapter was developed to offer practical guidance, operational tables, and checklists that can be used in daily care.

Patient safety is not a destination, but a continuous process of improvement. Trained professionals, committed managers, informed patients, and guided companions form the basis of a truly safe hospital culture.

Dental Access Alert: Preventing falls is preventing suffering. Each fall avoided represents one less injury, a shorter hospital stay, faster recovery, and a more dignified experience for the patient and their family.

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Chapter 12 – Frequently Asked Questions about Fall Prevention

This section addresses the most common questions from healthcare professionals, managers, patients, and companions about fall prevention in a hospital setting.

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For healthcare professionals and managers

How often should fall risk be assessed?
Upon admission and whenever there is a relevant clinical change, such as surgery, introduction of high-risk medications, changes in mobility, or a fall episode.

Which assessment scale should I use?
The scale should be defined by the institutional protocol. The most commonly used for adults are the Morse Fall Scale and the Johns Hopkins. For pediatrics, the Humpty Dumpty is widely adopted.

Is the use of side rails mandatory for all patients?
No. Side rails should be used according to clinical indication, assessed individually. Indiscriminate use can be considered physical restraint and requires specific criteria.

How to act when a patient refuses preventive measures?
Orient them again, document the refusal in the patient's chart, communicate with the team, and involve the companion when possible. Never impose measures without adequate ethical and clinical evaluation.

What to do when no companion is available?
Intensify team supervision, prioritize attending to patient requests, and adopt environmental measures that reduce the need for independent mobilization.

How to reduce underreporting of falls?
Promote a blame-free safety culture, clarify the importance of reporting for process improvement, and facilitate access to the reporting system.

Who is responsible for fall prevention?
The entire multidisciplinary team, including doctors, nurses, technicians, physiotherapists, pharmacists, and support staff, as well as the patients and companions themselves.

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For patients and companions

Why do I need to wear a risk identification wristband?
The wristband alerts the entire team to the need for additional care, ensuring that any professional who comes into contact with you takes appropriate preventive measures.

Can I get up by myself to go to the bathroom?
It depends on your clinical condition. If you have been instructed to ask for help, use the call bell before getting up. This simple measure significantly reduces the risk of falling.

What footwear should I wear during hospitalization?
Prefer closed-toe shoes with non-slip soles. Avoid loose flip-flops, regular socks on smooth floors, and walking barefoot.

Can my companion help me get up?
The companion can offer support but should not perform transfers or mobilizations without team guidance, especially for patients with mobility limitations.

What should I do if I feel dizzy when getting up?
Sit down immediately on the edge of the bed, hold on firmly, and ring the call bell. Do not try to walk while dizzy.

Are bed rails mandatory?
Rails are used according to clinical indication. If you have questions about the need in your case, talk to the nursing team.

What to do if you witness a fall?
Do not try to lift the patient alone. Immediately ring the call bell or call the nursing team.

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About equipment

Can I use the IV pole for support when walking?
No. The IV pole is not designed to support body weight and can tip over, causing a fall and damage to the venous access.

How do I know if I need a walker or a cane?
The indication should be made by the physical therapy team or the responsible physician, based on an assessment of your gait and balance.

How often should equipment be inspected?
Before each use and according to the institution's preventive maintenance plan. Defective equipment should not be used.

Do non-slip socks replace adequate footwear?
Non-slip socks are a valid alternative in specific situations, but closed-toe shoes with non-slip soles offer greater protection and stability.

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About specific situations

Do patients who have already fallen have a higher risk of falling again?
Yes. A history of falls is one of the main predictive factors for new occurrences and should be considered in risk assessment.

Do hospitalized children need special care?
Yes. Falls in pediatrics have their own characteristics and require constant supervision, the use of age-appropriate beds, and detailed guidance for guardians.

Do pregnant and postpartum women have a higher risk of falling?
Yes. Physiological changes such as hypotension, fatigue, and pain can temporarily compromise balance and mobility, especially in the immediate postpartum period.

Do patients with dementia need specific measures?
Yes. Patients with cognitive changes often do not recognize their own limits and require more frequent supervision, verbal reorientation, and active family participation.

Can the risk of falling change during hospitalization?
Yes. The risk is dynamic and can increase or decrease according to clinical evolution, medications used, and environmental conditions.

Dental Access Alert: Questions about fall prevention are common and legitimate. Well-informed professionals make safer decisions. Informed patients and companions actively participate in prevention. Continuous education is one of the most effective pillars of any patient safety program.

Chapter Summary: Fall prevention involves multiple actors and distinct situations. Answering the most frequent questions clearly and objectively contributes to adherence to preventive measures, reduces risky behaviors, and strengthens the safety culture throughout the institution.

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Conclusion

Fall prevention in a hospital environment is a shared responsibility. There is no single measure capable of completely eliminating this risk, but the combination of systematic assessment, proportionate preventive measures, an appropriate environment, correct equipment, effective communication, and active participation from patients and companions significantly reduces the occurrence of adverse events.

Throughout this guide, we have covered the main aspects involved in fall prevention: from understanding how accidents happen in practice to implementing and monitoring institutional protocols. Each chapter was developed to offer practical guidance, operational tables, and checklists that can be used in daily care.

Patient safety is not a destination, but a continuous process of improvement. Trained professionals, committed managers, informed patients, and guided companions form the basis of a truly safe hospital culture.

Dental Access Alert: Preventing falls is preventing suffering. Each fall avoided represents one less injury, a shorter hospital stay, faster recovery, and a more dignified experience for the patient and their family.

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References

This guide was prepared based on the following official sources and reference publications:

• Brazilian Health Regulatory Agency (ANVISA). Fall Prevention Protocol. Brasília: ANVISA/FIOCRUZ, 2013.
• Ministry of Health. Reference document for the National Patient Safety Program. Brasília: Ministry of Health, 2014.
• Ministry of Health. Ordinance No. 529, of April 1, 2013. Establishes the National Patient Safety Program (PNSP).
• Brazilian Health Regulatory Agency (ANVISA). RDC No. 36, of July 25, 2013. Establishes actions for patient safety in health services.
• Joint Commission International. Accreditation Standards for Hospitals. 6th ed. Oakbrook Terrace: JCI, 2017.
• World Health Organization (WHO). WHO Global Report on Falls Prevention in Older Age. Geneva: WHO, 2007.
• Morse, J.M. Preventing Patient Falls. 2nd ed. New York: Springer, 2009.
• Federal Nursing Council (COFEN). COFEN Resolution No. 543/2017. Updates and establishes parameters for the dimensioning of the nursing professional staff.
• National Institute for Health and Care Excellence (NICE). Falls in older people: assessing risk and prevention. Clinical Guideline CG161. London: NICE, 2013.

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