Prevention of Hospital Falls

An RWJF national program

Field of Work: prevention of patient falls in hospitals

Problem Synopsis: Patient falls have long been a common and serious problem in hospitals across the nation, causing substantial injury, even death. Researchers at the Washington University School of Medicine in St. Louis analyzed 183 patient falls at a local hospital over a three-month period and found that 42 percent resulted in some type of injury and 8 percent involved moderate or severe injuries, including lacerations, fractures, head traumas and one "cardiac arrest with death." The risk of serious injury from a fall increases with age, making older patients especially vulnerable.

Synopsis of the Work: In 2006–2007, eight hospital organizations collaborated with the Institute for Healthcare Improvement (IHI) in Cambridge, Mass., to test a preliminary package of interventions aimed at preventing harmful patient falls. Informed by feedback from the hospital sites, an IHI team developed and disseminated a final package of strategies to prevent injuries from patient falls in acute care hospital units.

Key Results

  • In 2008, IHI published on its website a 75-page guide, Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls, to help hospital staff identify patients at risk for serious injury from a fall and to implement interventions to prevent or mitigate fall-related injuries.

    Most of the hospitals that piloted the interventions demonstrated reduced rates of fall injuries or showed "promising downward trends" in fall injuries, the IHI team reported. However, data inconsistencies and a constrained testing period made it difficult to evaluate whether improvements resulted from the interventions, the team cautioned.

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