OR workers have to mentally multitask when sharps are in use, focusing simultaneously on patient and worker safety. The human tendency is to devise a pecking order, and most often, patient safety comes first. Even if there is unexpected bleeding during a procedure, and speed becomes a factor, patient safety is still at the fore, right? This is by no means wrong - it's just that you must give worker safety nearly as much attention. Taking steps to reduce patient falls is always prudent. It might also be timely, as one of JCAHO's 2005 National Patient Safety Goals calls for facilities to "assess and periodically reassess each patient's risk for falling."

Causes of falls
You're probably seeing lots of elderly patients, who are far more susceptible to falling and sustaining injury. Falls may be caused by environmental or physiologic factors.

• About 14 percent of all falls in hospitals are accidental - that is, they occur when patients fall unintentionally because they have slipped or tripped because of an equipment failure or because of another environmental factor.
• Another 8 percent are unanticipated physiologic falls that occur when the physical cause of the fall isn't reflected in the patient's risk factor; it can't be predicted nor prevented.
• And 78 percent are anticipated physiologic falls, occurring in patients whose scores on risk assessment scales (see "The Morse Fall Scale" on page 78) indicate they're at risk.

It's generally accepted that patient falls are caused by multiple factors, both intrinsic and extrinsic. Intrinsic factors include a previous fall, reduced vision, unsteady gait, chronic illness (such as diabetes) or an affected musculoskeletal system (by something such as osteoporosis). Extrinsic factors include medication/anesthesia/analgesia, the design of beds and chairs, condition of ground surfaces in your facility, footwear and inadequate assistive devices.

Preventing falls
Here are 15 steps you can take to reduce falls.

• Instruct patients to request assistance as needed.
• Instruct patients to wear non-skid footwear.
• Provide an appropriate armchair with wheels locked at the patient's bedside.
• Ensure the pathway to the restroom is free of obstacles and properly lighted.
• Keep hallways clear of obstacles.
• Place assistive devices (if needed) such as walkers and canes within a patient's reach.
• Raise the side rails as appropriate for access to bed controls, support and repositioning.
• Evaluate chair and bed height.
• Consider how long the anesthetics and analgesics will affect level of consciousness, gait and elimination when planning patient care.
• Check environment for potentially unsafe conditions, such as loose carpeting and water on the floor. Notify appropriate personnel of hazardous conditions.
• Do not leave at-risk patients unattended in diagnostic or treatment areas.
• Ensure patients or residents being transported by stretcher/bed have all side rails in the up position during transport, or if left unattended briefly while awaiting tests or procedures.
• Inform and educate patients and family members regarding a plan of care to prevent falls.
• Include the patient's family in the development of an individualized safety plan if necessary, considering age-specific criteria and patient cognition when planning care.
• Communicate the patient's at-risk status during shift report and with other disciplines as appropriate.
• Consider sitters for patients with an impaired ability to understand or follow directions; these non-licensed patient-care staff provide continuous one-on-one observation under the direction of an RN who monitors the patient's actions.

Risk assessment: tools and timing
Key to a successful falls-prevention program is systematically identifying patients who are at a higher risk for falling so you can target fall-prevention resources where they're most needed. Several risk assessment tools are available that may provide guidance in the development of a fall prevention program for each setting and population; whichever you choose, it should be systematic, usually assigning points to specific risk factors. Nurses usually assess patients for risk factors at the following times:

• on admission - risk-assessment data should be entered into the admission database as soon as possible after admission;
• changes in a patient's status - physiological, functional or cognitive change;
• whenever a fall occurs - you should enter data any time a patient experiences a fall; and
• periodically during their stay, or when transported, including transfers to another patient care unit.

In addition to assessing risk factors and implementing interventions, you should have a system in place for defining and reporting falls, measuring and monitoring fall rates, and improving the falls prevention program. Only by developing a baseline and subsequently measuring your progress will you know what you might do differently to reduce falls and fall-related injuries.

Basic steps include requiring that all staff complete education and training on the medications patients will be given both pre- and post-op, how to assess patients, environmental strategies for preventing falls and what to do if a fall occurs

Holistic approach to safety
There's no simple fall-prevention strategy that will work for all patients. That's why, as falls appear to happen because of a complex interaction of intrinsic and extrinsic risk factors, interventions require a multi-faceted approach. A strong fall-prevention strategy that encompasses a number of different interventions and targets multiple risk factors is most likely to succeed.