Morse Fall Risk Assessment Tool

The Morse Fall Risk Assessment Tool is a widely used instrument for evaluating the risk of patient falls in healthcare settings. It measures several key factors to determine a patient's fall risk level. (Dixe et al., 2022)

History of Falling

Assesses whether the patient has fallen within the past 3 months or during the current hospitalization. This factor is crucial as previous falls are a strong predictor of future fall risk. (Dixe et al., 2022)

Secondary Diagnosis

Evaluates if the patient has more than one medical diagnosis. Multiple diagnoses can increase fall risk due to complex health conditions and treatments. (Dixe et al., 2022)

Ambulatory Aid

Assesses the patient's need for assistance in walking. This includes:

• No assistance needed
• Use of crutches, cane, or walker
• Furniture support (patient leans on furniture for support while walking)

The type of aid used can indicate the level of mobility impairment and associated fall risk. (Dixe et al., 2022)

Intravenous Therapy

Considers whether the patient has an IV or heparin lock. IV therapy can increase fall risk due to potential mobility restrictions and side effects of medications. (Dixe et al., 2022)

Gait

Evaluates the patient's walking and transferring style. This factor assesses:

• Normal gait
• Weak gait (short steps, may shuffle)
• Impaired gait (difficulty rising from chair, head down, balance problems)

Gait assessment is crucial in determining the patient's stability and likelihood of falling. (Dixe et al., 2022)

Mental Status

Assesses the patient's awareness of their own ability to move around. This factor evaluates whether the patient:

• Is oriented to own ability
• Overestimates or forgets limitations

A patient's mental status can significantly impact their fall risk, especially if they are unaware of their physical limitations. (Dixe et al., 2022)

Scoring and Risk Levels

The Morse Fall Scale uses a point system to categorize patients into risk levels:

• 0-24 points: No risk
• 25-50 points: Low risk
• ≥51 points: High risk

This scoring system helps healthcare providers determine appropriate fall prevention interventions. (Dixe et al., 2022)

Limitations and Considerations

• The Morse Fall Scale may not capture all fall risk factors for specific patient populations, such as psychiatric patients. (Jamaluddin et al., 2022)
• It does not directly assess factors like medication use or specific mental health conditions that may contribute to fall risk. (Jamaluddin et al., 2022)
• Regular reassessment is necessary as a patient's fall risk can change during hospitalization. (Khan & Shahzad, 2024)

Effectiveness and Implementation

• The Morse Fall Scale has shown effectiveness in reducing fall rates when implemented as part of a comprehensive fall prevention program. (Khan & Shahzad, 2024)
• It is widely endorsed by nursing staff for its ease of use and quick administration (typically less than 3 minutes). (Khan & Shahzad, 2024)
• Proper staff training and consistent application are crucial for maximizing the tool's effectiveness in fall prevention strategies. (Khan & Shahzad, 2024)