1. Zhao, Yunchuan (Lucy) PhD, RN
  2. Bott, Marjorie PhD, RN
  3. He, Jianghua PhD
  4. Kim, Heejung PhD, RN
  5. Park, Shin Hye PhD, RN
  6. Dunton, Nancy PhD, RN


Falls and injurious falls are a major safety concern for patient care in acute care hospitals. Inpatient falls and injurious falls can cause extra financial burden to patients, families, and healthcare facilities. This article provides clinical implications and recommendations for adult inpatient fall and injurious fall prevention through a brief review of factors associated with falls and injurious falls and current fall prevention practices in acute care hospitals.


Article Content

The problem of adult inpatient falls and injurious falls in acute care hospitals has been a serious safety concern for patient care. In acute care hospitals, inpatient falls are the most common incidents reported by nurses and other healthcare team members.1-4 In the United States, the average fall rate is about 3 to 5 falls per 1000 patient days with approximately 1 million annual falls in hospitals. Falls during hospitalization can have numerous negative consequences to patients and families, including fear of falling, depression, injuries, reduced mobility and functional ability, and decreased independent living and quality of life.4,5


Injuries resulting from inpatient falls can cause extra financial burden and decreased revenue to healthcare facilities. On average, injurious falls lead to an increased length of hospital stay by 6 to 12 days and an additional cost of $13,316.6 Because the Centers for Medicare and Medicaid Services no longer reimburses hospitals for treatment of preventable injuries, including fall-related injuries,7 not only will hospitals pay the extra cost for these fall-related injuries, hospitals will sustain revenue losses.


Falls and falls-related injuries are listed as one of the nursing-sensitive care outcome measures by the National Quality Forum.8 It is essential to prevent inpatient falls and related injuries so as to deliver high-quality care. To deliver high-quality care, nurse leaders in acute care hospitals need to have: a) the knowledge of specific risk factors associated with inpatient falls and injurious falls; b) common fall prevention interventions; and c) potential strategies for effective fall and injurious fall prevention in acute care hospitals. The information presented hereinafter will assist nurse leaders to develop organizational policies and programs that aim at effective fall and injurious fall prevention targeting adult inpatients.


Factors Associated With Falls and Injurious Falls

Evidence shows that inpatient falls and injurious falls are a complicated phenomenon that involves multiple factors, including intrinsic and extrinsic factors.4,9,10 Intrinsic factors are patient-specific factors, and extrinsic factors include hospital organizational factors, nurse staffing, and nursing process factors.


Intrinsic Factors

Evidence demonstrates the association between advanced age, and inpatient falls and injurious falls.11-15 Among inpatient falls, about 50% occur in patients 60 years and older, whereas patients older than 80 years are significantly at the highest risk for falls and injurious falls.11,14,15 Interestingly, the evidence on the relationship between gender and falls is inclusive because both genders are identified as a risk factor for falls or injurious falls in previous studies11-13,15,16 or no association is identified at all.10 Certain medical conditions such as cognitive impairment, impaired mobility, hypertension, osteoporosis, and stroke also are risk factors for falls or injurious falls.4,9,11,16 However, being on anticoagulation therapy does not place patients at an increased risk for bleeding injury after a fall.17,18


Extrinsic Factors

Hospital and unit organizational characteristics also are found to be associated with patient falls and injurious falls. Teaching and Magnet(R) hospitals in general have less falls and injurious falls.10,19,20 In these hospitals, nurses often report higher perceptions of the quality of work, work environment, nursing leadership, and job satisfaction, which all contribute to better quality of care and patient outcomes.20,21 According to recent studies, mixed results are reported when analyzed by unit type-surgical units have an increasing rate of falls or injurious falls10,22-although previous studies suggested that medical units had the highest rates of falls and injurious falls.19,23


Several nursing process factors significantly contributing to falls and injurious falls require attention from nurse administrators and managers. Fall risk assessment and fall prevention protocols are 2 important nursing process factors in preventing falls and injurious falls.12,19 Patients who are identified at risk for falls through fall risk assessment are 21% less likely to have injurious falls.10 In clinical practice, nurses often initiate a fall prevention protocol to patients identified at fall risk. With a fall prevention protocol implemented, falls are more likely to be assisted by employees, which can reduce fall-related injuries.10,19 Studies indicate that falls without employee assistance are 50% more likely to result in injuries than falls with employee assistance.10-13,19 Because about 12% to 69% of falls are related to urinary and bowel elimination needs, providing assistance when patients need to go to the bathroom is essential in preventing falls.9


Fall Prevention Interventions

Existing Fall Prevention Interventions

In the last decades, many fall prevention interventions have been developed and implemented in acute care hospitals. Based on the characteristics of intervention components, fall prevention interventions can be categorized into (a) environmental, (b) educational, (c) communicational, or (d) nursing process interventions.2,4,24


Environmental Interventions

Environmental interventions may focus on the efforts to create a clutter-free, safe environment.2,4 Specifically, environmental interventions include modifying the hospital environment with vinyl flooring2,25 and ensuring the patient bed is in low position.24 Modifying the hospital environment with vinyl flooring helps prevent falls because hospital units with carpeted floors have increased fall rates compared with units with vinyl floors.2,25 However, lowering hospital beds shows no significant effect in preventing inpatient falls.4,26


Educational Interventions

Staff and patient education on fall prevention are 2 major components of educational interventions.2,24 Staff education is used to raise staff awareness of fall prevention or provide training for fall risk assessment tools.2,4 Patient education programs aim to improve patient knowledge of: a) fall prevalence and consequences; b) causes of falls; c) hospital fall prevention strategies; and d) self-reflection of individual risk and a goal-setting review.27,28 Evidence shows that staff or patient education as a single intervention strategy has been effective in preventing inpatient falls and injurious falls.2,4 With education, staff and patients often have improved knowledge on fall risks and positive attitudes on fall prevention. Education can also help staff implement appropriate fall preventions and promote active patient engagement in fall prevention.4,26,28


Communicational Interventions

Communicational interventions use visual alert signs, verbal communications, or electronic alarm systems to assist fall prevention. Visual signs including yellow wristband and fall risk signs alert staff to the patients at a high risk for falling.2,4,24 Electronic bed or chair alarms alert staff to the movement of high-fall risk patients so that the staff can provide assistance or support.4,24 Awareness posters (ie, call don't fall, keep calm) remind the patient to call staff for help to prevent falls.2,24 These communicational interventions often are used in combination with other fall prevention strategies.4,24,29


Nursing Process Interventions

Nursing process interventions aiming to prevent falls include fall risk assessment, fall protocol implementation, and postfall review/evaluations.4,24,29 Fall risk assessment is the most common nursing process intervention.24,29 Based on fall risk assessment, a fall prevention protocol often is implemented on patients identified at a high risk for falls. A fall prevention protocol usually consists of patient education; visual alert signs; electronic alert systems; care, safety, and toileting rounds; and ambulation assistance.4,24 Care, safety, and toileting rounds, often referred to as hourly rounding, is a common practice in acute care hospitals. During these rounds, nursing staff purposely check on the patients at regular intervals to ensure patients are receiving the care and assistance as needed.30 As a single intervention, hourly rounding has proved to be an effective strategy in preventing falls and improving patient satisfaction of nursing care.25,30 Postfall review or evaluations that have shown some effectiveness in preventing future or recurrent inpatient falls31 are used in many hospitals.4,24,29


Issues With Existing Fall Prevention Interventions

Falls and injurious falls are still prevalent in many US hospitals.23 Yet, the effectiveness of existing fall prevention interventions varies.2,4,24 In the literature, several major issues that affect the success of hospital fall prevention interventions are identified including fall risk assessment, fall prevention components, and intervention implementation and adherence.4,24,29


Fall Risk Assessment

Most fall prevention intervention approaches include fall risk assessment.24,29 Fall risk assessment often is conducted with an assessment tool or nursing judgment. However, a recent systematic review of hospital fall prevention programs revealed that more than half of the studies used an assessment tool that did not have reported validity and reliability testing.24 Because fall risk assessment is an important approach for fall prevention, using an assessment tool that does not have reported validity and reliability testing may threaten the accuracy of the assessment. As a result, fall assessment may not correctly identify patients at risk for falls.32


Fall Prevention Components

Most fall prevention interventions consist of multiple common components including fall risk assessment, patient and staff education, visual alert signs, and hourly rounding.4,24,29 However, an optimal bundle of intervention components cannot be identified because there has not been strong evidence on what components are most important for successful fall interventions.29


Intervention Implementation and Adherence

The implementation and adherence of fall prevention interventions has been a determining factor in successful fall prevention programs. Without appropriate implementation and adherence, fall interventions may not be effective in preventing falls and injurious falls.24,29 Major challenges in the implementation and adherence of fall prevention interventions include poor organizational prioritization of fall prevention, complacent staff attitude toward fall prevention, and poor compliance with existing fall prevention protocols.33-36


Clinical Implications and Recommendations

Existing evidence suggests that inpatient falls and injurious falls can be complicated. Therefore, preventing falls and injurious falls can be challenging. Nurse administrators and nurse managers need to consider multilevel factors associated with inpatient falls and injurious falls. Based on the evidence on the effectiveness of and issues in the existing fall prevention interventions, the following strategies should be used in fall and injurious fall prevention interventions to improve the success of fall prevention interventions. Table 1 lists examples of effective multicomponent fall programs and implementation strategies.

Table 1 - Click to enlarge in new windowTable 1 Fall Intervention Components and Implementation Strategies

Provide Strong Leadership Support

Leadership support has been identified as an essential factor for successful fall and injurious falls prevention in acute care hospitals in several systematic reviews of inpatient fall prevention programs.24,29 With strong leadership support, patient safety and fall prevention are established as organizational priorities and a culture of patient safety is emphasized and promoted throughout the hospitals, which facilitates fall prevention interventions.24,29,35,36


Develop Appropriate Prevention Programs

Evidence suggests individualized fall prevention interventions are important in preventing falls and injurious falls. Given the known risk factors for inpatient falls and injurious falls and the positive impact of fall assessment on fall prevention,12,19 all fall prevention programs should begin with an appropriate fall risk assessment. Commonly used adult fall assessment tools include Morse Fall Scale (MFS), St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY), Hendrich II Fall Risk Model (HIIFRM), and Johns Hopkins Fall Risk Assessment Tool (JHFRAT). Among these tools, MFS and HIFRM have positive predicative validity in identifying patients at a high risk for falls, whereas STRATIFY and JHFRAT are better in differentiating patients at low fall risks from those at high risks24,43,44 (Table 2).

Table 2 - Click to enlarge in new windowTable 2 Fall Risk Assessment Tools

For high-fall risk patients, appropriate fall prevention intervention should be developed based on the results of fall assessment. Multicomponent interventions with different combinations of fall prevention strategies have been effective in hospitals with different sizes, locations, and teaching status.24,27,29,36-42 Although the components of these fall intervention program vary, the success of these multicomponent programs suggests that an effective fall prevention program should include the following components: fall risk assessment, fall alert signs, staff education, patient education, movement alarms, and hourly rounding especially assessing patients' need for toileting.29,36-42


In addition to these interventions, an individualized fall prevention plan needs to be developed by considering different patient populations in various hospital units. For example, research suggests that surgical units have more injurious falls among inpatient falls compared with medical, medical-surgical, and step-down units.10 In acute care hospitals, many surgical units have implemented the Enhanced Recovery After Surgery programs, in which early postoperative mobilization is promoted.45,46 With early postoperative mobilization, patients can develop orthostatic intolerance that further causes falls and injurious falls.47,48 The administration of analgesic medications to postoperative patients also increases these patients' risk for falls because of the side effects of analgesics.47-50 Fall prevention interventions on surgical units need to be focused on providing ambulatory assistance by employees given the association between early postoperative mobilization and falls. Research shows that falls with employee assistance result in significantly less injurious falls compared with falls without employee assistance.10-13,19 Therefore, providing employee assistance to patients as needed is a critical method for injurious fall prevention.


For older adult patients, medication review is an essential component of fall interventions. Hospitalized older adult patients often have chronic diseases with multiple medications. Polypharmacy is independently associated with adverse outcomes including falls. Certain medications commonly prescribed in older adult patients, including antihypertensive, antiepileptics, psychotropics, and opioid analgesic drugs, contribute to falls because of the side effects of sedation, orthostatic hypotension, and confusion.47-50 Nurses need to carefully review medications in older adult patients and take appropriate actions to prevent falls.


Enhance Intervention Implementation and Adherence

To ensure successful fall prevention, nurse leaders must ensure successful fall prevention intervention implementation and adherence. Given the issues of complacent attitude and poor compliance with existing fall prevention protocols in intervention implementation and adherence,33-36 staff education should be enhanced and staff should be engaged in fall prevention to change staff attitudes and improve intervention implementation and adherence. Staff education on the importance of patient safety and fall prevention has been an effective strategy in changing staff's complacent attitude toward fall prevention.33,34 Staff involvement is a key factor in successful fall prevention interventions. In many successful fall prevention programs, frontline nursing staff are engaged in the intervention design and implementation as either members of the multidisciplinary fall prevention team or the unit champions for fall prevention enhancement.33,34,36 The involvement of frontline nursing staff has improved the compliance with fall prevention protocols, enhanced intervention implementation, and increased intervention adherence.33,34,36 Nursing leadership should engage frontline nursing staff in fall prevention intervention development and implementation to ensure buy-in from staff and successful adoption of the prevention strategies.


In the implementation of fall prevention interventions, nurse staffing is an important factor that nursing leadership needs to consider. Evidence shows a relationship between nurse staffing (ie, total nursing hours per patient day [TNHPPD], RN hours per patient day [RNHPPD], and proportion of RN hours) and inpatient falls and/or injurious falls.10,18,20,22 Previous studies suggest negative associations between inpatient fall rates with lower TNHPPD and proportion of RN hours.20,22 The relationship between injurious fall rates and TNHPPD, RNHPPD, and proportion of RN hours is complicated. The results of a recent study on injurious fall rates among inpatients who fell showed a nonlinear relationship between injurious fall rates and RNHPPD. The optimal RNHPPD approximately reaches 5 in relation to injurious falls: the higher the RNHPPD before it reaches 5, the lower injurious falls; after RNHPPD reaches 5, the relationship becomes positive.10 Given the nonlinear association between injurious fall rates and nurse staffing, nurse leaders need to ensure proper and adequate staffing in patient care. Without adequate staffing, it is challenging for nursing staff to implement appropriate fall prevention interventions to prevent falls and injurious falls.



Inpatient falls and injurious falls in acute care hospitals are a complicated phenomenon that makes fall and injurious fall prevention a challenge for nurse administrators and managers. To ensure prevention interventions for falls and, more importantly, injurious falls are successful, multicomponent prevention and valid assessment under strong leadership should be implemented to focus on safety and quality nursing care. In addition, involving frontline staff in the development and implementation of fall prevention interventions and fall risk assessment is important for buy-in and successful adherence. Other strategies for successful fall prevention intervention adherence are staff education and appropriate nurse staffing. In addition, nurse leaders need to develop fall prevention interventions based on effective intervention strategies with the consideration of known factors associated with inpatient falls and injurious falls.




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