11.1 Patient Safety: Falls, Restraints & Equipment

Falls are the most frequently reported hospital adverse event, and injurious falls are largely preventable with structured screening and bundled interventions. The MEDSURG-BC exam expects you to know the screening tool, the prevention bundle, and the correct nursing response when prevention fails.

Fall Risk Screening: The Morse Fall Scale

The Morse Fall Scale (MFS) is the most widely used adult inpatient fall-risk tool. It scores six items; add the points for every item that applies.

Risk bands: 0–24 = no risk, 25–50 = low risk, greater than 50 = high risk (some facilities use 25–44 low and 45+ high; know the widely taught 25/50 cutoffs). Screen on admission, after any change in condition or transfer, after a fall, and per facility schedule (commonly each shift for high-risk patients).

Clinical pearl: the single heaviest-weighted item is a prior fall (25 points). A patient with a fall history, an IV, and forgetful mental status already scores 60 — high risk before gait is even assessed.

Fall Prevention Bundle

Universal precautions apply to every patient; intensified measures apply to high-risk patients.

• Environment: bed in the lowest position with wheels locked, call light and personal items within reach, non-skid footwear (never socks alone on bare floors), dry uncluttered floors, adequate lighting, assistive devices within reach.
• Purposeful hourly rounding addressing the 4 P's: pain, positioning, potty (toileting), and possessions. Scheduled toileting eliminates most unassisted bathroom trips, where the majority of falls occur.
• High-risk identifiers: fall-risk wristband, door signage, yellow or color-coded gown/socks, bed and chair exit alarms, low beds with floor mats, and relocation to a room near the nurses' station.
• Medication review: sedatives, hypnotics, opioids, diuretics, antihypertensives, and hypoglycemics raise fall risk through sedation, orthostasis, urgency, or hypoglycemia. Collaborate on deprescribing when possible.
• Orthostatic precautions: for patients on antihypertensives or after prolonged bed rest, dangle at the bedside before standing and assess for orthostatic hypotension (a drop of ≥20 mm Hg systolic or ≥10 mm Hg diastolic within 3 minutes of standing).

Post-Fall Response

The exam tests the sequence. Assess first — move second.

1. Stay with the patient; call for help. Do not move the patient until injuries are ruled out.
2. Perform a rapid head-to-toe and neurologic assessment; check vital signs. If head strike or loss of consciousness occurred or is unwitnessed, initiate neuro checks per protocol (typically every 15 minutes × 4, then tapering) and maintain cervical spine precautions if indicated.
3. Move safely with assist; return the patient to bed using a lift if needed.
4. Notify the provider and the family; obtain orders for imaging (CT head is common for patients on anticoagulants — warfarin, apixaban — even without visible injury).
5. Document objectively: what was found, assessment findings, who was notified and when, interventions. Complete an incident/occurrence report — it is a quality-improvement document and is never referenced in the medical record.
6. Reassess and update the fall-risk score and care plan; continue monitoring for delayed injury for 24–72 hours.

Restraints: Types and Regulations

A restraint is any device, method, or medication that restricts a patient's freedom of movement or access to their own body and cannot be easily removed by the patient.

• Physical restraints: limb (wrist/ankle) holders, vests, mittens, belts. Side rails count as a restraint when raised to keep a patient from getting out of bed against their wishes (four raised rails are generally treated as a restraint). Devices that are part of treatment — orthopedic traction, IV arm boards, procedural positioning — are not restraints.
• Chemical restraints: medications such as haloperidol, lorazepam, or quetiapine given specifically to control behavior or restrict movement rather than to treat an assessed condition.
• Seclusion (behavioral settings): involuntary confinement alone in a locked room.

Regulatory Requirements (CMS and The Joint Commission)

• Least restrictive first: all alternatives must be tried and documented before a restraint is applied.
• Order required — never PRN. Restraints may never be ordered "as needed." A licensed independent practitioner's order must specify type, reason, and duration. In a true emergency a nurse may apply a restraint, but the order must be obtained immediately afterward (per facility policy, typically within 1 hour).
• Violent/self-destructive (behavioral) restraints require a face-to-face evaluation by the provider within 1 hour of initiation. Order time limits: 4 hours for adults 18+, 2 hours for ages 9–17, 1 hour for children under 9 — then a new order is required.
• Non-violent (medical/surgical) restraints: orders are renewed per facility policy, commonly every 24 hours.
• Monitoring: assess circulation, skin integrity, nutrition/hydration, toileting, and range of motion — typically every 2 hours with temporary release for ROM and skin care; behavioral restraints often require continuous 1:1 observation. Tie limb restraints with a quick-release (slip) knot to the bed frame — never to the side rails — and fit two fingers between the device and skin.
• Documentation: behavior necessitating restraint, alternatives attempted, patient/family education, type and time applied, assessments and releases, and the earliest possible discontinuation. Restraints are discontinued as soon as the behavior resolves — not held to the order's expiration.

Alternatives to Restraints

Try and document these first: diversion activities (music, folding tasks), family or trained sitters/companions, bed and chair alarms, low beds, frequent toileting, pain and delirium assessment, concealing or securing IV lines and tubes (arm sleeves, abdominal binders), room near the nurses' station, orientation aids, and treating reversible causes of agitation (hypoxia, hypoglycemia, urinary retention, pain, infection).

Medical Equipment Safety

• Infusion pumps: verify pump programming against the order; use the smart-pump drug library and soft limits. Perform an independent double check by two nurses for high-alert medications (insulin, heparin, concentrated electrolytes, opioids) — both clinicians independently verify patient, drug, dose, rate, and line attachment. Never bypass drug-library alerts casually.
• Alarms: cardiac monitors, pumps, ventilators, and bed alarms are safety devices. Never silence, pause, or turn down an alarm without first assessing the patient. Customize alarm parameters to the individual patient to fight alarm fatigue, and respond promptly to every alarm — treat each as real until proven otherwise.
• Hospital beds: check brakes before transfers; be aware of the FDA's bed-entrapment zones (gaps around the mattress, rails, head/foot boards) for small or confused patients; ensure mattress and rail fit the frame.
• Tubes and drains: label lines, trace every tube from patient to source before giving or connecting anything, and never force connections — tubing misconnections (e.g., enteral formula into an IV) are sentinel events.

Safe Patient Handling

Manual lifting is the leading cause of nursing injury. The National Institute for Occupational Safety and Health (NIOSH) lifting equation limits safe manual lifting to about 35 pounds of patient weight under ideal conditions. Use mechanical aids — ceiling lifts, sit-to-stand devices, friction-reducing slide sheets, and transfer/gait belts — and assess the patient's weight-bearing ability and cooperation before every transfer. Do not catch a falling patient; guide them to the floor while protecting the head to avoid injuring yourself.

Electrical, Oxygen, and Fire Safety

• Electrical: use only grounded three-prong plugs and facility-inspected equipment; report frayed cords and sparks; do not use patient-owned electrical devices without biomedical inspection.
• Oxygen is a medication requiring an order. Secure tanks upright in holders, keep oil, grease, and petroleum-based products away (use water-soluble lubricant for nasal dryness), post no-smoking/open-flame precautions, and know the RACE fire response: Rescue/Remove patients, Activate the alarm, Contain (close doors), Extinguish/Evacuate. PASS operates the extinguisher: Pull, Aim, Squeeze, Sweep.

Radiation, Laser, and MRI Safety

• Radiation (diagnostic and brachytherapy): minimize exposure through time, distance, and shielding. For implanted radiation sources (e.g., cervical brachytherapy), limit time at the bedside, wear a dosimeter badge, use lead shielding, and restrict pregnant staff and visitors; save a dislodged implant with forceps into a lead container — never with bare hands.
• Laser: post warning signage, cover windows, provide wavelength-specific eye protection for staff and patient, and use non-reflective instruments to prevent stray-beam injury.
• MRI: the magnet is always on. Screen every patient and staff member for ferromagnetic objects — pacemakers and older aneurysm clips, implants, pumps, shrapnel, and even some tattoos. Observe zone restrictions; never bring oxygen tanks, monitors, or IV poles that are not MRI-conditional into the scanner room. Projectiles pulled into the bore can be lethal.