Case in the Spotlight 11

Case details:

You are about to admit a patient.  Mr Jones,  is being admitted with a urinary tract infection. His wife reports he has been a little confused, and he has frequency of urination, getting up five times per night, previously had prostatism.  He is a bit deaf, wears glasses, but is generally pretty well apart from some osteoarthritis of his hips. His medications include temazepam 10mg nocte, aspirin 100mg daily, pantoprazole 40mg daily, and paracetamol 1g qid and endone 5mg tds prn.  Lucky for you this is going to be a relatively straightforward BEST POSSIBLE MEDICATION RECONCILLIATION form to complete. 

Insert example after admission. DRUG CHART AND FORM.

However, just when you think you are done, the admitting nurse is completing their assessment and asks you if the patient needs a falls alert.

Question 1  How many points indicate a patient is at High risk of Falling?
Answer :3 or more

Question 2  Are all patients who score less than 3 at low risk of falling.
Answer:  No

Some patients who score less than 3 would be considered at risk of falling. 

Nurses exercise clinical judgement in addition to the Fall risk score in determining  the patients risk level (High or Low)

Examples include- young patients with brain injury, amputees, pregnant women with pelvis instability, patients with visual impairment, patients with poorly controlled epilepsy, diabetic patients at risk of hypoglycaemia,  drug or alcohol affected patients, all patients in the immediate post-operative period.

Falls risk assessment

Question 3 What actions are required by medical staff if a patient is assessed as high risk of falling. 

  • A) Consider ordering investigations to identify reversible risk factors.

For example: Recent falls.  Investigate, cardiac, endocrine, neurological causes, Mental state.  Investigate infection,  injury,  or  hypoxia related confusion.

  • B) Treat/ manage risk factors.
  • C) Place the bed in its lowest position before leaving patients on a bed, unsupervised.

Question 5 Medications.  Which of the following drugs are considered Culprit drugs for increasing a patient’s risk of falls.
Answer: The following agents are frequently cited in falls events

  • Anti- psychotics, Sedatives, anti- depressants, Anti- Parkinson’s , diuretics, anti-hypertensives, Hypnotics

In this patient, the oral opiates and the nocte benzodiazepine are important.

Question 6 What are the actions to be taken for patient identified at admission as taking 4 or more medications?

  • The Doctor will liaise with the clinical Pharmacist to consider their recommendation for ceasing  or altering the drug regime.
  • The clinical pharmacist will review the patient’s current medications within 24 hours of admission.  If culprit drugs are identified the pharmacist will make a recommendation in the patient progress notes outlining any possible changes.  At BHS this is identified with a medication sticker

falls sticker

Question 7 What is the 'Falls 6 PACK'
Answer:  Falls 6 PACK are 6 strategies implemented for patients identified as at risk of falls.

To implement 6 PACK correctly the fall alert sign as well as at least one other strategy must be implemented.

risk score

This is how the 6 Pack appears in the Patient Management Plan

Question 8  POST FALL MANAGEMENT  When is medical review required post fall?

  • Immediately
  • At 6 hours post fall
  • At 24 hours Post fall.


0 hours
  • What happened and what can be done?
  • Injury?
  • Observations and BGL?
  • Investigations?
  • Transfer?
  • Medication?
  • Additional Medical or Surgical review ?
  • Referrals ?   (Physiotherapist, Occupational Therapist, Continence Nurse, Cognition Nurse, Podiatry etc)
6 hours
  • Is the patient stable? 
  • Can they now be monitored less frequently? ( 4/24 observations)
  • Have investigations been completed and  what are the results? 
  • What else has happened? 
  • How does the Health Care Team prevent the next fall?
  • Are referrals made?
  • Has the patient been seen by those they were referred to
  • Recommendations from Allied Health, Specialists  and CNC’s?
  • Medication review?
24 hours
  • Is the patient SAFE? 
  • Can the patient return to the pre-fall regime of observations?
  • Are all test results considered?
  • Are there any changes to be made to management to prevent the next fall.