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The morse fall scale is a valuable tool used by healthcare professionals to assess fall risk factors in hospitalized patients. By evaluating various items such as patient history, secondary diagnoses, ambulatory aids, intravenous therapy, gait, and mental status, healthcare providers can identify patients at risk for falls and implement preventative measures. The total score can predict future falls, but it's essential to address the identified risk factors. Instructions on how to use the morse fall scale and offers resources for training and integration into electronic health records.
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3H: Morse Fall Scale for Identifying Fall Risk Factors
Background: This tool can be used to identify risk factors for falls in hospitalized patients. The total score may be used to predict future falls, but it is more important to identify risk factors using the scale and then plan care to address those risk factors.
Reference: Adapted from Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging 1989;8:366-7. Reprinted with the permission of Cambridge University Press.
How to use this tool: A training module on proper use of the Morse Fall Scale developed by the Partners HealthCare Fall Prevention Task Force may be found at www.brighamandwomens.org/Patients_Visitors/pcs/nursing/nursinged/Medical/FALLS/Fall_TI PS_Toolkit_MFS%20Training%20Module.pdf. In addition to completion of the module, training should include real cases where the provider conducts an assessment. Mental status and gait parameters require actual assessment of a real patient (as opposed to solely a chart review).
This tool can be used by staff nurses. Use this tool in conjunction with clinical assessment and a review of medications (see Tool 3I) to determine if a patient is at risk for falls and plan care accordingly. Note that this scale may not capture the risk factors that are most important on your hospital ward, so consider your local circumstances.
Register through Partners HealthCare at www.brighamandwomens.org/Patients_Visitors/pcs/nursing/nursinged/Medical/FALLS/Permissi ons/PHS%20MFS%20Competency.pdf prior to use.
If your hospital uses an electronic health record, consult your hospital’s information systems staff about integrating this tool into the electronic health record.
Morse Fall Scale
Item Item Score Patient Score
Total Score‡: Tally the patient score and record. <25: Low risk 25 - 45: Moderate risk
45: High risk ______