Enhancing Patient Safety: The Persistent Challenge of Patient Falls  

Patient falls are among the most reported patient safety incidents for hospitals.  According to The Joint Commission, the number of unexpected patient safety occurrences involving death or serious physical injury (Sentinel Events) classified as falls increased by almost 450% from 2018 through 2022;  The number of reported falls increasing from 138 (2018) to 611 (2022).  Of these incidents, 11% resulted in patient death in 2022.  Patient falls comprise 48% of reported Sentinel Events for the first half of 2023, making it the most frequently reported patient safety occurrence.  

In addition to the physical and emotional impact of patient falls, the costs that are placed on hospitals in addressing patient falls are staggering.  In 2015, the direct medical costs totaled $637.5 million for fatal fall injuries and $31.3 billion for non-fatal injuries.¹  Since 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing hospitals for costs related to patient falls.  Therefore, these costs are placed on the facility, which, combined with the extended patient days resulting from a fall, reduces the availability of patient care resources that can affect all patients.

Given the incident and cost data, it is evident that patient falls is one of the most frequent and costly patient safety incidents plaguing our healthcare system.  Despite the number of initiatives that hospitals have implemented to address this issue, it remains a persistent issue that organizations are struggling to reduce.  It is imperative that facilities implement a robust fall prevention program to ensure that initiatives are established, monitored, and maintained. 

A Fall Prevention Program Requires an Interdisciplinary Approach

All falls should not be considered true accidents as a coordinated multidisciplinary clinical team approach can reduce their occurrence.  Identification of underlying risk factors combined with coordinated interventions to mitigate these risks has been shown to reduce the incidence of inpatient falls by 20–30%.²   The key to an effective organization’s Fall Prevention Program is that it is a  multidisciplinary obligation rather than a nursing-centric responsibility for planning and intervention.  Leadership support is essential to ensure that fall prevention is kept at the forefront of organizational goals.  Allocation of resources, training support, and accountability is vital to a robust program and can only be supported through engaged Leadership.  Medical Staff are an indispensable part of the Falls program through their assessment of the patient’s history, systems, and medication regimen, they can ensure that fall risk is identified and addressed in the patient’s interdisciplinary plan of care.  Pharmacy can provide alerts to the Provider and Nursing staff as to the increased risk of falls related to the patient’s medication therapy.  Other members of the healthcare team such as Radiology, Physical Therapy, Dietary, and Environmental Services, are instrumental in recognizing patients at risk for falls, identifying patients displaying unsafe behaviors, and alerting those providing direct patient care with concerns.  Nursing, by virtue of its greater touch time with patients, is in a unique position to assess for fall risk on an ongoing basis and ensure prevention measures are effectively initiated.

Lessons From the Field

A review of common findings associated with patient fall prevention from mock and actual surveys indicates the most common opportunities are as follows:

  • Failure to follow organizational policies and procedures – organizations have robust and detailed policies and procedures in place but they are not followed by staff.  
  • Fall risk assessments not performed during admission or periodically as required by policy.
  • Fall risk assessments indicate a fall risk but interventions not initiated. 
  • Fall risk patients not effectively monitored (Rounding/use of alarms).
  • Organizations not collecting/trending falls program compliance data.
  • Failure to consider the impact of other patient conditions on their ability to follow instructions, for example, Alzheimer/Dementia and certain medication regimens.

Key Elements of an Effective Program

Staff Education and Engagement

Staff must be aware of the program’s elements, their responsibilities, and the impact of patient falls on the organization.  Staff must be engaged and support the program.  The recent pandemic has impacted on staffing and orientation of new staff.  Organizations should review their staff education and orientation programs to their Falls Reduction Program. 

Patient Education

A robust and organized approach in educating patients and their families on the Fall Prevention Program and their part in supporting safety is critical.  Considerations must be made regarding patients experiencing memory loss, dementia or delirium.  

Individualized Plan of Care

The plan of care must be sensitive to individual patient’s risk factors, needs, and preferences to be truly effective.

Consistent and Repetitive Assessment of Patient Fall Risk

The cornerstone of patient fall risk prevention is conducting an initial risk screening and a consistent rhythm to the re-assessment process to ensure the identification of any changes that will affect care initiatives.  

Proactive Fall Risk Initiatives

Once an individualized plan of care has been developed, the team must initiate proactive initiatives to reduce the risk of falls for the patient.  This may include education, use of banding/signage to indicate high fall-risk patients and those in need of mobility assistance. Many organizations have implemented Tele-sitting programs.  These programs are designed to monitor the patient for any at-risk behaviors and alert a virtual staff member who can then verbally interact with the patient while simultaneously when needed, alerting the bedside staff that assistance is needed.

Purposeful Rounding / Proactive Toileting

According to the American Nursing Association, “purposeful rounding is a proactive, systematic, nurse-driven, evidence-based intervention that helps us anticipate and address patient needs.”  Not only does this practice help reduce falls, but it increases team communication and patient satisfaction.  Data has also demonstrated that a significant percentage of patient falls can be associated with toileting with some sources indicating these comprise between 40-50% of patient falls.  Proactive Toileting, a part of purposeful rounding, reduces risk of falls associated with elimination by encouraging the patient to toilet regularly during rounds rather than relying on the patient to call for assistance.

Evaluating Program Effectiveness

Considering that falls pose a significant risk to patient safety, it is vital that the organization can demonstrate that it is evaluating the effectiveness of its program and addressing opportunities.  This requires an active monitoring program that reviews all aspects of your fall program, including collecting and analyzing data to determine opportunities and drivers of fall incidents.  This should include tracing for program compliance, compliance with fall risk assessments, and implementation of interventions when risk has been identified.  A retrospective review of fall incidents should also follow a standard method to identify contributing factors.  These factors should be trended and modifications to the fall prevention program enacted if gaps are identified.  Data must be communicated to leaders and bedside staff so they can understand how efforts align with the program and impact patient safety.


Falls present a daunting challenge to healthcare organizations that not only affect your patients physically, mentally and emotionally, but can extract a financial cost that takes away from the resources needed to provide care.  It is incumbent on facility leaders to take time to review their Falls Prevention Program and commit to reducing this patient safety issue.  Is it effective?  What does your data show?  What do you need to do to move forward?

¹Burns ER, Stevens JA, Lee R. The direct costs of fatal and non-fatal falls among older adults - United States. J Safety Res. 2016 Sep;58:99-103. doi: 10.1016/j.jsr.2016.05.001. Epub 2016 May 28. PMID: 27620939; PMCID: PMC6823838.
²Morris, R., & O'Riordan, S. (2017). Prevention of falls in hospital. Clinical medicine (London, England), 17(4), 360–362. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297656/. 17-4-360.

To learn more about the prevention of patient falls contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.

Leave a Comment

Your email address will not be published. Required fields are marked *

Shopping Cart