NURS 6051N, Section XX
Paper title here
Information regarding the level of risk a patient has for falling can be conveyed in many
ways such as in a report from one nurse to another, as part of the assessment, a diagnosis, in the
daily safety briefing, and as recorded in the electronic health record (EHR). Incorporating
technology into the workflow can help prevent falls and improve patient safety. “Workflow is the
sequence of physical and mental tasks performed by various people within and between work
environments” (U.S. Department of Health & Human Services, n.d.). Falls are dangerous,
bringing further complications and injury to patients. This paper describes the present way
information is conveyed from admission onward regarding a patient’s risk for fall and explores
areas where improvement can occur.
Explanation of Flowchart
A patient came to the emergency room and admitted to the hospital. Depending on
diagnosis and emergency healthcare staff involved with the patient a determination is made
regarding the patient’s risk for falling. If the patient’s diagnosis is fall, change in mental status,
or ambulatory dysfunction the patient is automatically classified being at high risk for falling. In
this case patient interventions to prevent falls should be initiated in the emergency room by the
nurse caring for the patient. When admitting this patient, it is evident the patient is at high risk
The patient with a different diagnosis is not considered a falls risk until information is
gained to status otherwise. When admitting this patient to the floor, the nurse has no knowledge
of the degree of risk for falling, unless the ER nurse has completed a falls risk assessment of the
patient. Emergency nurses have access to the falls risk assessment but rarely complete this
assessment if it is not related to the patient’s admitting diagnosis. “There is evidence in the falls
prevention research literature which suggests that in excess of 50% of potential falls relating to
older adults are avoided as a result of ongoing falls prevention interventions” (Hamm, Money,
Atwal & Paraskevopoulos, 2016, p.319).
When a patient arrives on the floor, the present instructions for the admitting nurse are to
review the patient’s medications, complete a database, and assessment, all done within the within
the patient’s EHR. While reviewing medications and completing the database, determining the
patient’s orientation is quickly assessed. If a patient is not entirely oriented, they are then
determined to be at risk for falls. At this time the nurse initiates the falls risk protocol or
delegates this task to the clinical assistant. The protocol includes yellow socks and blanket,
alarms for the bed and chair, as well as placing a falls risk sign outside the room. The nurse also
must choose a care plan for the patient called “risk/actual for fall” in the electronic health record.
If the patient is fully oriented they are not considered at risk for falling at this time, unless
As the process of admission continues the nurse completes the full assessment. The nurse
then charts on the patient in the electronic health record using a modified Morse Falls Risk
assessment tool to determine if the patient is at risk for falling. The needed information to
complete the falls risk is a history of falls, secondary diagnosis, ambulatory aid, IV or attached
equipment, and orientation. A score generates from the assessment questions. With a score more
than or equal to 45, the falls risk protocol is put into place if less than 45 the patient is not at risk
for falling. At this time if the patient scores 45 or higher the care plan “risk/actual for fall” is
automatically entered into the care plan segment of the electronic health record.
Once the patient is on the floor, the policy states the falls risk assessment tool should be
completed once daily until discharge occurs, if there is a change in mental status, or the patient
falls. Conveying of the patient’s the risk of falling is done at bedside report to the oncoming
nurse. Education to the patient regarding the risk of falling is completed by the day shift nurse
when reviewing the daily care plan. Charting in the electronic health record documents the
assessment, teaching, and outcomes of the falls risk/prevention.
Metrix used to calculate the falls is measured by how many falls occur within a 1000
patient hospitalization day, if the falls prevention protocol was in place at the time of the fall, and
outcomes of the fall. Falls are reported through an event reporting system and reviewed by
management and the Falls Council.
The Falls Council includes floor nurses, managers, clinical nurse leaders, and nursing
assistants. They track, initiate, and adapt the fall protocol taking into consideration evidence-
based practices and the measured outcomes from our falls prevention protocol. “Although many
tools to accomplish workflow redesign are available, the best method is the one that compliments
the organization and supports the work of clinicians” (McGonigle & Mastrian, 2015, p.241).
Having nurses and nursing assistants as part of the Falls Council ensures clinicians have a say in
the workflow. Improvements can be made in the workflow of falls prevention.
Areas of Improvement
There are many areas which need improvement when conveying information regarding
the falls risk of patients. Once a patient is assessed as a falls risk there should be a notification
which shows a red “Falls” sign in the electronic record. “Often, however, this underlying design
conflicts with the needs of clinicians, who must see a wide range of information in formats that
allow quick review” (Koppel & Kreda, 2010, p. 9). Completion of the falls risk assessment
should take place when the patient is in the emergency room and the protocol should then be put
into place once the patient is determined to be at risk for falling. There have been incidences
where a patient is brought up from the emergency room by transport and placed in their room
without notification to the nurse receiving the patient. Enacting the protocol in the ER, the
patient would have yellow socks and blanket indicating to the transport staff the patient is at risk
for falling. Having a red “Falls” flag advising all the staff from the floor secretary to the clinical
assistants, the patient is at risk for falling. ER nurses have access to the falls risk assessment tool
in their electronic assessment, and it should be utilized to help prevent falls.
Another area of improvement utilizing technology will be placing a falls diagnosis on the
patients’ electronic health record if the patient has fallen recently. It would then be part of the
electronic record and help by giving the floor nurse a heads up that the patient has had a previous
fall. Emanuele (as cited in Huser, Rasmussen, Oberg, & Starren, 2011) suggested:
Work-flow-enabled EHR system, which can communicate bi-directionally with a
Workflow Management System…send EHR event notifications to the work-flow engine
and display in the EHR system tasks and alerts generated by the workflow engine. (p.19)
Also, since completion of the electronic patient database is before the patient assessment, it
would be wise to consider the falls risk assessment be part of the database and if positive for risk
of falls it could generate a falls risk care plan and intervention in the nurse’s patient assessment.
Finally, I suggest the patient falls risk score as a requirement each shift rather than daily.
Many patients who are not at risk for falls during the day shift, become falls risks at night. This
risk is missed by only requiring the fall assessment daily.
Using the workflow of conveying falls risk information has encouraged thinking and
planning with the use of technology beyond the current protocol to prevent falls and increase the
safety of patients. There are many new technologies used to enhance nursing care and workflow.
Technology can help convey and alert healthcare workers of relevant information regarding
patients. According to Choi, Lawler, Boenecke, Ponatoski, & Zimring (2011), Fall-prevention
models can assist hospital staff with the development of a balanced fall prevention plan including
technology to prevent falls and fall-related injuries” (p.2522). It is important to be aware of and
step back to evaluate the process making sure the technology is effectively being used to
improve patient care and outcomes. Technology can alert nurses that a patient is at risk for
falling by having a positive falls risk score, and it can convey this finding by placing a record of
the score on the patient’s electronic health record.
Choi, Y., Lawler, E., Boenecke, C. A., Ponatoski, E. R., & Zimring, C. M. (2011). Developing a
multi-systemic fall prevention model, incorporating the physical environment, the care
process and technology: a systematic review. Journal Of Advanced Nursing, 67(12), 2501-
2524 24p. doi:10.1111/j.1365-2648.2011.05672.x
Hamm, J., Money, A. G., Atwal, A., & Paraskevopoulos, I. (2016). Fall prevention intervention
technologies: A conceptual framework and survey of the state of the art. Journal Of
Biomedical Informatics, 59 319-345 27p. doi:10.1016/j.jbi.2015.12.013
Huser, V., Rasmussen, L. V., Oberg, R., & Starren, J. B. (2011). Implementation of workflow
engine technology to deliver basic clinical decision support functionality. BMC Medical
Research Methodology, 11(1), 43-61. doi:10.1186/1471-2288-11-43
Koppel, R., & Kreda, D. A. (2010). Healthcare IT usability and suitability for clinical needs:
challenges of design, workflow, and contractual relations. Studies In Health Technology
And Informatics, 157, 7-14.
McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge
(3rd ed.). Burlington, MA: Jones and Bartlett Learning.
U.S. Department of Health & Human Services. (n.d.) Workflow assessment for health IT toolkit.
Retrieved from http://healthit.ahrq.gov/portal/server.pt/community
CA/RN Apply falls
+ Fall Risk
Assess Daily for Risk of Fall
Conveying Fall Risk Information
– Falls Risk
Pt in ER Admitted
Floor RN calls ER RN for report
Pt. not fully oriented Pt. fully oriented
RN completes admission (med review, data base, and assessment)
– Falls Risk Risk
Pt. dx falls/CMS/ ambulatory dysfunction