1. clinical governance
1.1. Preventing slips, trips and Falls
1.1.1. Spillages
1.1.1.1. clean up spills and dry and put up sign
1.1.2. cables
1.1.3. obstructions
1.1.3.1. maintain clutter free patient care areas
1.1.4. Flooring
1.1.4.1. keep floor surface clean
1.1.5. footwear
1.1.6. lighting
1.1.6.1. provide night light
1.1.7. Report the incident
1.2. Give orientation of the room and the toilet
1.3. keep hospital bed in low position with brakes locked
1.4. install handrails in patient bathroom , room and hallway
1.5. Home hazard assessment
1.6. Culturally competent practice
2. Lead/coordinate/ direct
2.1. Lead
2.1.1. help staff to learn new practice
2.2. Coordinate
2.2.1. collect data and quality improvement
2.3. Direct
2.3.1. Educate nurses in unit level ongoing combination and reporting
2.3.1.1. Fill in a risk-man post fall ()
2.3.2. availability of resources on the ward
2.3.2.1. Gaite aids
2.3.2.1.1. Education on its use ( )
2.3.2.2. proximate alarm
2.3.2.3. sensor mat/ floor mat
2.3.2.4. ongoing education
3. Evaluate and Monitor Safety
3.1. Risk Assessment/screening
3.1.1. Patient centred care
3.1.1.1. Engage patient and family in developing care plan
3.1.1.1.1. Give pamphelt on Falls Prevention to take home ( )
3.1.1.2. feedback on care provided
3.1.2. Staff/Nurse
3.1.2.1. Routine Practice
3.1.2.1.1. communicate recent fall and or / risk of harm
3.1.2.1.2. walking aid are within patient's reach
3.1.2.1.3. Ensure bedside table and belongings are within patient's reach
3.1.2.1.4. ensure flosses are clean and hearing aids are working
3.1.2.1.5. ensure nurse call bell is within patient's reach
3.1.2.1.6. ensure good fitting footwear or anti-slip socks
3.1.2.1.7. IV assistance when walking
3.1.2.1.8. Aware of rapid functional and cognitive status
3.1.2.1.9. Sensor mat or floor mat
3.1.2.1.10. proximate alarm
3.1.2.1.11. Assisting out of the bed/ assistance with in and out of the bed
3.1.2.1.12. Toilet Scheduling
3.1.2.1.13. continues observation and hourly rounding
3.1.2.2. Falls risks
3.1.2.2.1. history of falls
3.1.2.2.2. medication side effects
3.1.2.2.3. Apprprprate walking aids
3.1.2.2.4. Aware of IV pole
3.1.2.2.5. unsteady walking
3.1.2.2.6. may forget or chose not to call.
3.1.2.3. Documentation / Handover
3.1.2.3.1. Document falls and risk of fall on daily
3.1.2.3.2. Share risk assessment in care plan
3.1.2.4. Risk Assessment tools
3.1.2.4.1. GCS
3.1.2.4.2. Fall risk assesment
3.1.2.4.3. history of fall
3.1.2.4.4. gait deficit
3.1.2.4.5. balance deficit
3.1.2.4.6. muscle weakness
3.1.2.4.7. Age<65