NR 599 Week 5 Patient Safety Proposal Example

Patient Safety Proposal: Make the Morse Fall Scale Reassessment Event-Driven and Require a Fresh Rescore After Any Sedative, Opioid or Diuretic, With the Evidence Given Up Stated

Student Name

College of Nursing, Chamberlain University

NR 599: Nursing Informatics for Advanced Practice

Instructor Name

Month Day, Year

Patient Safety Proposal: Make the Morse Fall Scale Reassessment Event-Driven and Require a Fresh Rescore After Any Sedative, Opioid or Diuretic, With the Evidence Given Up Stated

One Harm, With Its Mechanism

The harm: an unassisted fall in the early morning by a patient whose fall risk rose overnight because of a new sedative-hypnotic, opioid or diuretic, while the record still showed the score from before the medication.

The mechanism: the Morse reassessment is required every 12 hours regardless of what happens between. A nurse who files it at 23:00, before giving zolpidem at 23:30, has met the rule. The record then shows a low score until 11:00 the next day. On our unit, 6 of the 14 falls in the first half of 2026 happened between 03:00 and 07:00 in patients who had received one of these medications after their last score.

The Change

One build object: the condition on the "Morse Fall Scale" reassessment requirement.

Today: due every 12 hours.

Proposed: due at admission, on transfer to the unit, within 1 hour after the first dose of any medication in three classes (sedative-hypnotics, opioids, loop diuretics) since the last score, within 1 hour after a fall, and when a nurse records a change in mental status. Not otherwise due for a patient whose last score is under 72 hours old.

This is a single change to the requirement's trigger. The overdue alert reconfiguration from the alert brief, approved for pilot in December, follows the same rule.

The Attention Returned

From the burden analysis, routine reassessments take about 49 minutes a day on the unit. Under the proposed rule, the flowsheet report for June shows about 12 reassessments a day would be due: admissions, transfers, the three medication classes and changes in mental status. Twelve scores at the observed median come to roughly ten minutes daily, so about 39 minutes a day would go back to nurses, roughly 240 hours a year on one unit.

Those minutes come back at specific times: the 23:00 and 11:00 reassessment rounds, which currently fall during medication passes.

The Evidence Surrendered

The change gives up a twice-daily timed record of fall risk for every patient.

Fall investigations would no longer find a score within 12 hours of every fall. For a stable patient with no qualifying event, the last score might be several days old.

The quality department's monthly measure of "Morse documented every 12 hours" would end and need replacing with "Morse documented within 1 hour of a qualifying event."

Routine reassessments that catch a change for reasons the rule cannot see, such as gradual weakness, would no longer happen; the nurse's own judgment and the mental status trigger would have to cover those.

Oliver et al. (2010) argue that fall prevention depends more on what is done for patients at risk than on repeated scoring, which supports giving up the routine score; but it remains a real loss of record.

Why These Three Medication Classes

Sedative-hypnotics, opioids and diuretics are the medications most often associated with falls in hospital through drowsiness, dizziness or urgency to reach the toilet. The Morse scale includes items for gait and mental status that these medications affect (Morse et al., 1989). A score taken after the first dose captures that change.

A Measure That Watches for Harm

Primary: the unit's fall rate, counted against occupied bed days. Baseline: January to June 2026, 14 falls in 5,180 patient days, 2.7 per 1,000.

Harm measure: the rate of falls causing injury, on the same denominator. Baseline: 3 injurious falls, 0.58 per 1,000.

Process: share of qualifying events followed by a Morse score within 1 hour. Target: 90%.

Watch measure: falls in patients with no qualifying event in the 72 hours before the fall, to see whether the rule misses patients whose risk changed for other reasons. Baseline: 4 of 14 falls.

Baselines were taken from the incident reporting system and the flowsheet report on 1 July 2026, before any change.

What the Evidence Says About Scores and Judgment

Reviews of fall risk tools in hospital have found that they predict falls only moderately, and that a nurse's own judgment does about as well (Oliver et al., 2004). The proposal does not claim that event-driven scoring predicts better; it claims that scoring when risk is likely to have changed is a better use of the same tool than scoring on a timer.

How the Build Would Work

The analyst would replace the twelve-hour timer with a rule that watches for qualifying medication administrations, transfers, falls and mental status entries, and creates a "due" task on the nurse's worklist. A maximum interval of 72 hours ensures that every patient is rescored at least every three days. The analyst estimates eight hours to build and test, using functions already in the record.

What Nurses Would Be Told

A one-page summary for each nurse: when the score is now due, why the twelve-hour rule was removed and that a nurse who sees a change for any other reason should rescore without waiting for a prompt.

What Happens to Patients Without a Qualifying Event

A patient admitted for an infection, who receives no sedative, opioid or diuretic and remains alert, would be scored at admission and then at 72 hours. A nurse who notices new weakness, unsteadiness or confusion can rescore at any time and is expected to; the mental status trigger covers confusion automatically. The watch measure exists to find falls in this group.

Why Not Simply Reinforce the Existing Rule

The alternative would be to keep the twelve-hour rule and remind nurses to rescore after sedatives. The burden analysis found that routine scores are already repeated without assessment in about one case in seven, and the late-entry case on our unit showed a nurse filing a score before giving zolpidem. A reminder adds to the documentation it is meant to fix. Changing the trigger places the score at the moment risk changes.

Who Decides

The Clinical Decision Support Committee approves changes to documentation requirements. The nursing practice council must also approve, because the change alters the unit's documentation policy.

Pilot and Review

Three months on our unit from 1 January 2027. Review in April: if falls per 1,000 patient days rise above 3.5, or falls in patients with no qualifying event exceed 3 in the quarter, the rule returns to every 12 hours while the committee reviews.

References

Morse, J. M., Morse, R. M., & Tylko, S. J. (1989). Development of a scale to identify the fall-prone patient. Canadian Journal on Aging, 8(4), 366-377. https://doi.org/10.1017/S0714980800008576

Oliver, D., Daly, F., Martin, F. C., & McMurdo, M. E. T. (2004). Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age and Ageing, 33(2), 122-130. https://doi.org/10.1093/ageing/afh017

Oliver, D., Healey, F., & Haines, T. P. (2010). Preventing falls and fall-related injuries in hospitals. Clinics in Geriatric Medicine, 26(4), 645-692. https://doi.org/10.1016/j.cger.2010.06.005