Falls risk assessment is a core component of patient safety in hospital practice. While prevention strategies are essential, they rely on accurate and repeated identification of risk factors.
A structured multifactorial falls risk assessment (MFRA) should be completed for at-risk patients on admission and reviewed regularly. This article provides a practical deep dive into how falls risk is assessed on the ward, how this informs clinical decision-making and is the third part in our article series on clinical risk assessment.
Contents
Who Needs a Falls Risk Assessment?
Falls risk assessment should be completed in:
- All patients aged ≥65
- Patients with a history of falls
- Those with mobility, cognitive, or neurological impairment
- Patients with acute illness or frailty
Assessment should occur on admission (ideally within hours) and be repeated if the patient’s condition changes or after a fall.
What is a Multifactorial Falls Risk Assessment?
A multifactorial falls risk assessment (MFRA) is a structured evaluation of multiple contributing factors, rather than relying on a single score.
It typically includes:
- Clinical history
- Physical assessment
- Cognitive assessment
- Medication review
- Environmental factors
This approach recognises that falls are rarely due to a single cause.
Key Components of Falls Risk Assessment
1. Falls History
A detailed history is essential:
- Previous falls (especially within the last year)
- Frequency and circumstances
- Associated symptoms (e.g. dizziness, blackout)
This is one of the strongest predictors of future falls.
2. Mobility and Functional Status
Assess:
- Baseline mobility
- Gait and balance
- Need for walking aids
Patients with impaired mobility or unsafe transfers are at significantly higher risk.
3. Cognitive Assessment
- Screen for delirium or dementia
- Assess awareness of risk and ability to follow instructions
Cognitive impairment increases risk due to poor judgement and reduced safety awareness.
4. Cardiovascular Assessment
- Measure lying and standing blood pressure
- Assess for postural hypotension
- Review symptoms such as dizziness or syncope
Postural drops in blood pressure are a common reversible cause of falls.
5. Medication Review
Identify medications that increase falls risk:
- Sedatives and hypnotics
- Antihypertensives
- Polypharmacy
Medication-related risk is significant—particularly with recent changes or new prescriptions.
6. Vision and Sensory Assessment
- Check vision (including use of glasses)
- Assess hearing where relevant
Impaired sensory input reduces ability to navigate safely.
7. Continence and Toileting Needs
- Urgency or frequency
- Night-time toileting patterns
Unmet toileting needs are a common contributor to unassisted mobilisation and falls.
8. Environmental Assessment
- Bed height and positioning
- Clutter or trip hazards
- Access to call bell and personal items
The immediate bedside environment plays a key role in inpatient falls.
9. Footwear and Equipment
- Assess appropriateness of footwear
- Ensure walking aids are available and suitable
Poor footwear or lack of aids significantly increases risk.
Risk Stratification and Clinical Judgement
While some tools (e.g. FRAT) may be used, risk assessment should not rely solely on scoring systems.
Instead, clinicians should:
- Identify modifiable vs non-modifiable risk factors
- Use clinical judgement alongside structured assessment
- Recognise that risk is dynamic and can change daily
High-Risk Clinical Situations
Certain situations are associated with increased falls risk:
- Early admission period
- Acute illness (e.g. infection)
- Delirium or agitation
- After sedative or PRN medication
- Night-time periods
These require increased vigilance and reassessment.
Reassessment and Ongoing Review
Falls risk assessment is not a one-off task.
It should be repeated:
- Within 24 hours of admission (or earlier if required)
- After any fall or near miss
- When clinical condition changes
Risk may fluctuate frequently, particularly in patients with delirium or acute illness.
Documentation and Care Planning
Assessment findings should directly inform care:
- Document identified risk factors clearly
- Develop an individualised care plan
- Communicate risk status to the wider team
Accurate documentation ensures continuity and safety.
Key Principles
- Falls risk assessment should be multifactorial and structured
- Previous falls and mobility impairment are key predictors
- Risk is dynamic and requires regular reassessment
- Clinical judgement is as important as assessment tools
- Assessment should directly inform individualised care planning
Further Reading
- Read how an MDT approach can work to Prevent Falls on the Ward
Written by Dr A Sidhu (CT2)
