In this article, Rehabilitation Expert, Christian Mongrain discusses falls in the healthcare setting. He covers the impact of falls, why they occur, and best demonstrated practices utilized by healthcare professionals to reduce the incidence and severity of fall incidents.

Falls in Hospitals and other Healthcare Settings

Falls are the most common adverse event reported in hospitals. According to the National Quality Measures Clearinghouse, falls are a leading cause of hospital-acquired injury, and frequently prolong or complicate hospital stays. Review of observational studies in acute care hospitals show that fall rates range from 1.3 to 8.9 falls/1,000 patient days. Falls occur at higher rates (8.9 to 17.1 falls/1,000 patient days) in units that focus on eldercare, neurology and rehabilitation. The Institute for Healthcare Improvement has identified falls as the leading cause of death in people 65 and older, with 10% of fatal falls for the elderly occurring in hospitals.

Falls resulting in injuries in the healthcare setting are on the rise. Depending on the setting, as many as 15% of inpatients experience at least one fall, and The Joint Commission estimates that 30% of falls in healthcare settings result in serious injury. Most falls in healthcare settings are multifactorial and require investigation of an experienced expert to identify factors causing the fall, and to determine if standards of care were provided to prevent it.

Source: Centers for Disease Control
Source: Centers for Disease Control

How are Falls defined in a hospital setting?

The National Quality Forum (NQF) defines a fall as an unplanned descent to the floor (or extension of the floor e.g., trash can or other equipment) with or without injury to the patient.

Why do people fall?

Risk factors associated with falls can be categorized as either Intrinsic or Extrinsic. Intrinsic factors include physiologic impairments that may be pre-existing due to a person’s past medical history, or new as they relate to the reason for admission. Extrinsic factors relate to the environment occupied.

To understand falls, one must first understand balance. Humans balance by taking input (received through vision, sensation, equilibrium, and proprioception), then processing it (in the brain), and then reacting via an output mechanism (such as moving one’s head, limbs, trunk, or eyes). When a person has a reduction in their ability to receive, process, or react appropriately to stimuli, they are more likely to lose their balance and fall.

  • Intrinsic/Physiologic factors:
  • Several physiologic factors influence a person’s risk for falls. Often a disease process or side effect resulting from a surgery or injury may have significance. For example, an injury or illness may lead to a person having weakness in one or more extremities, a decrease or absence of sensation, impaired or altered vision, or impaired safety awareness. Patients may also experience significant orthostatic hypotension (a sudden drop in blood pressure when transitioning to an upright position) due to side effects of medication, dehydration, or immobility.
  • Extrinsic/Environmental factors:
  • Environmental factors influence risk for falls. These can include slippery or uneven surfaces, obstacles or tripping hazards, inappropriate lighting, elevated noise levels, limited access to assistive devices or assistive equipment, and hazard related to the height of the bed, toilet, chairs, or equipment. There may also be opportunities for equipment failure due to poor maintenance, overloading, non-compliant pairing of equipment (mattresses to beds, slings to lifts, leg rests to wheelchairs, etc.), or misuse.
    The availability of the care provider (nurse, nursing assistant, therapist, etc.) may also impact a person’s risk for fall. This may be influenced by the staffing ratios (care providers to patients), staff training, and guidelines for safe patient handling. Healthcare facilities are required to ensure that their staff are competent and capable of providing safe care, and to provide patients with appropriate methods to request assistance when needed.

Falls have consequences

The cost of falls cannot only be measured by direct medical costs. People may also suffer from long-term effects of these injuries such as disability, dependence on others, lost time from work and household duties, and reduced quality of life.

What are healthcare providers doing?

Not every fall can be predicted or prevented. Many institutions apply techniques to identify patients at risk for falls and at risk of injury from falls, and then implement measures to prevent falls or reduce risk from injury. This may include one or more of the following techniques:

  • Screening patients for fall risk and fall-related injury risk factors on admission (osteoporosis or blood clotting abnormalities)
  • Creating a fall prevention and response team involving interdisciplinary healthcare workers
  • Reviewing plan of care and standards as they relate to falls
  • Communicating and educating staff and patients about patient fall risk and injury risks
  • Clearly identifying patients at increased risk for falls
  • Increasing the frequency and duration of patient observation
  • Completing assessments of the environment to identify and address fall hazards
  • Modifying the environment and equipment to reduce fall hazards
  • Assessing patient’s mobility prior to instructing patients to freely leave their bed
  • Training patients on the use of assistive devices like walkers, crutches, or wheelchairs

Through the effective development of fall prevention policies and procedures it is possible for healthcare facilities to reduce the incidence and severity of fall events. The healthcare experts at Robson Forensic are frequently retained to investigate disputes involving the adequacy of patient care and supervision. Contact our experts directly to discuss your case and how Robson Forensic can assist.


The experts at Robson Forensic are frequently retained to investigate the adequacy of care provided in hospitals, nursing homes and other healthcare facilities. Our experts can address many aspects of these cases from administrative policies and procedures, to the level of care provided by healthcare professionals, or the maintenance and custodial practices of care facilities.

For more information visit our Healthcare Supervision practice page.


Featured Expert

Christian H. Mongrain, MPT

Rehabilitation Therapist & Healthcare Expert

Christian Mongrain is a physical therapist and healthcare expert who has been actively involved in fall prevention, environment of care, and quality improvement councils in several hospitals. Since graduating with his Masters degree in Physical Therapy in 1999, Christian has worked as a therapist and director of therapies in hospital, LTACH, inpatient rehab, skilled nursing, and outpatient therapy centers. He applies his experience as a member of multidisciplinary teams to investigate incidents involving falls, patient handling, and unanticipated rehab outcomes.


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