Preventing Falls in Hospital: A Nurse’s Guide to Risk, Prevention and Post-Fall Care

Falls are among the most commonly reported patient safety incidents in hospitals worldwide. WHO identifies falls as the second leading cause of unintentional injury deaths globally, with adults over 60 at greatest risk. In hospital, a fall can cause a hip fracture or head injury, lengthen the stay, cause loss of confidence and independence, and sometimes death. Many falls can be prevented with good nursing assessment and simple measures.

Who is at risk?

• Older adults (NICE suggests everyone aged 65 or older in hospital should be considered at risk).
• Patients aged 50–64 with conditions that increase risk.
• A history of falls.
• Confusion, delirium or dementia.
• Walking or balance problems, weakness, recent stroke, Parkinson’s disease.
• Medicines: sedatives, sleeping tablets, opioids, antipsychotics, antihypertensives, diuretics, hypoglycaemic agents.
• Low blood pressure on standing (postural hypotension).
• Urgency or frequency of urination, incontinence, diarrhoea.
• Poor eyesight, unfamiliar environment, inappropriate footwear.

Multifactorial assessment

NICE advises against relying on falls risk prediction scores alone. Instead, assess and address each individual risk factor:

• Cognition: screen for delirium and dementia.
• Continence needs.
• Falls history, including causes and consequences.
• Footwear.
• Health problems that increase risk.
• Medication review with the prescriber or pharmacist.
• Lying and standing blood pressure (postural hypotension: a fall of 20 mmHg or more systolic, or 10 mmHg diastolic, on standing, or symptoms).
• Mobility and balance, with physiotherapy input.
• Vision.
• Syncope (fainting) history.

Practical prevention

• Call bell within reach, and check the patient knows how to use it.
• Bed at the lowest height, brakes on.
• Personal items within reach: glasses, water, phone, walking aid.
• Safe footwear: well-fitting, non-slip; not loose slippers or socks alone.
• Regular toileting rounds, especially at night and for patients on diuretics or laxatives.
• Good lighting, including night lights; clear, dry floors and uncluttered paths.
• Intentional rounding: checking patients regularly (often hourly) for pain, position, toileting and possessions.
• Bay nursing or closer observation for high-risk confused patients.
• Encourage mobility: keeping patients in bed causes deconditioning and increases falls later.
• Teach patients to get up slowly: sit on the side of the bed first.
• Involve families: ask what helps the person, and encourage them to tell staff before they leave.

Bed rails: not a simple answer

Bed rails can prevent people rolling out of bed, but in a confused person who tries to climb over them, they can increase the height of a fall or cause entrapment. Use them only after an individual assessment, and document the decision. Restraint (physical or chemical) is not a falls prevention strategy and carries serious risks.

After a fall: what to do

1. Don’t move the patient straight away. Call for help.
2. Assess A–E, including conscious level (GCS), and check for injuries, especially head injury and hip fracture (shortened, externally rotated leg, pain).
3. If there is any suspicion of spinal injury, keep the patient still and use specialist equipment to move them, per policy (e.g. flat lifting with a scoop stretcher or hover device).
4. If no injury is suspected, use safe moving and handling equipment to help the patient up.
5. Medical review according to policy, and promptly if there is a head injury, the patient takes anticoagulants, or there are signs of injury.
6. Neurological observations for patients with suspected head injury or unwitnessed falls, as per policy. Patients on anticoagulants are at higher risk of brain bleeding.
7. Inform the family and document fully; complete an incident report.
8. Review the falls prevention plan to prevent another fall.

Related: Glasgow Coma Scale · Head-to-toe assessment · Nursing documentation

Based on NICE guidance on falls in older people (NG249), the World Guidelines for Falls Prevention and Management for Older Adults (2022), and WHO falls information. Educational content: follow your local falls policy.