First Step to Reduce Falls in a Healthcare Facility
The first action should be implementing a systematic fall risk screening program that identifies high-risk patients, followed immediately by multifactorial risk assessment focusing on postural hypotension, medication review (particularly psychotropic drugs and polypharmacy ≥4 medications), and gait/balance evaluation. 1
Why Screening and Assessment Must Come First
You cannot intervene effectively without knowing who is at risk and what their specific risk factors are. The evidence is unequivocal that targeted interventions work, while untargeted programs do not 1. The BMJ guidelines explicitly state that interventions are most effective when targeting patients at high absolute risk of falls 1.
Critical Screening Questions
Ask all patients annually about:
Any affirmative answer triggers comprehensive assessment 2, 4.
The Core Assessment Components (Priority Order)
1. Medication Review (Highest Priority)
This must be done first because:
- Psychotropic medications show consistent association with falls across ALL settings 5, 6
- Polypharmacy (≥4 medications) is a major modifiable risk factor 5, 6, 3
- Medication reduction was a prominent component of effective fall-reducing interventions 6
Specifically assess:
- Total number of medications (flag if ≥4) 5, 6
- Vasodilators, diuretics, antipsychotics, sedative/hypnotics 5, 2
- Both long- and short-acting benzodiazepines (no difference in fall risk between them) 5, 6
2. Postural Hypotension Assessment
This is the second priority because attention to postural hypotension is "particularly effective" in fall prevention 1.
Measure:
3. Gait, Balance, and Transfer Assessment
These assessments identify who needs physical therapy referral 1.
Critical Implementation Pitfall to Avoid
Do NOT implement assessment without follow-through interventions and referrals. The BMJ provides Grade A evidence that "home assessment of risk and education in these areas without further referral does NOT reduce falls" 1, 5. Assessment alone is worthless—you must have a system for:
- Referral to primary physicians for medication review 5
- Occupational therapy for home safety with direct intervention 1, 5
- Physical therapy for balance/gait training 1, 5, 2
Why Other Approaches Should NOT Come First
Education Alone is Ineffective
Education without referral and intervention does not reduce falls (Grade A evidence) 1, 5. While education is important, it must be paired with actionable interventions 5, 7.
Environmental Modifications Alone Don't Work
Home environmental hazard modification alone shows equivocal or no benefit 6, 8. It only works when targeted to high-risk individuals identified through assessment 8.
Exercise Programs Need Targeting
Exercise programs for unselected older people should NOT be established (Grade *** recommendation) 1. They only work when targeted to those with identified deficits in strength and balance 1, 3.
The Algorithmic Approach After Initial Screening
For patients identified as high-risk:
- Within 7 days: Complete multifactorial assessment 5
- Immediate actions:
- Referrals based on findings:
For average-risk patients:
What Makes This Approach Evidence-Based
The BMJ guidelines (Grade A evidence) demonstrate that multifaceted programs combining assessment with targeted interventions reduce falls, while single interventions or assessment alone do not 1. A 2024 JAMA review confirms that multifactorial interventions reduced falls from 2317 to 1784 per 1000 patient-years (RR 0.77) among high-risk individuals 3.
The key is systematic identification followed by individualized intervention based on specific risk factors found during assessment 1, 7, 3.