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Morse Fall Scale: A Tool for Identifying Fall Risk Factors in Hospitalized Patients, Summaries of Nursing

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.

What you will learn

  • What are the risk factors identified by the Morse Fall Scale?
  • What is the appropriate training and resources required to use the Morse Fall Scale effectively?
  • How can the Morse Fall Scale be used to predict future falls?

Typology: Summaries

2021/2022

Uploaded on 09/12/2022

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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.
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Download Morse Fall Scale: A Tool for Identifying Fall Risk Factors in Hospitalized Patients and more Summaries Nursing in PDF only on Docsity!

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

  1. History of falling (immediate or previous) No 0 Yes 25 ______
  2. Secondary diagnosis (≥ 2 medical diagnoses in chart) No 0 Yes 15 ______
  3. Ambulatory aid None/bedrest/nurse assist Crutches/cane/walker Furniture

30 ______

  1. Intravenous therapy/heparin lock No 0 Yes 20 ______
  2. Gait Normal/bedrest/wheelchair Weak* Impaired†

20 ______

  1. Mental status Oriented to own ability Overestimates/forgets limitations

15 ______

Total Score‡: Tally the patient score and record. <25: Low risk 25 - 45: Moderate risk

45: High risk ______

  • Weak gait: Short steps (may shuffle), stooped but able to lift head while walking, may seek support from furniture while walking, but with light touch (for reassurance). † (^) Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down; significantly impaired balance, requiring furniture, support person, or walking aid to walk. ‡ (^) Suggested scoring based on Morse JM, Black C, Oberle K, et al. A prospective study to identify the fall-prone patient. Soc Sci Med 1989; 28(1):81-6. However, note that Morse herself said that the appropriate cut-points to distinguish risk should be determined by each institution based on the risk profile of its patients. For details, see Morse JM, , Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging 1989;8;366-7.