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  1. Soncrant, Christina MPH
  2. Neily, Julia RN, MS, MPH
  3. Bulat, Tatjana MD, CMD
  4. Mills, Peter D. PhD, MS


Background: Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts.


Purpose: This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events.


Methods: We categorized root cause analysis (RCA) reports and coded injury type, fall type, location, and root causes. We describe interventions during the fall and provide resources for future prevention.


Results: There were 154 reported fall RCAs during this time. Most (83%, n = 128) resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116).


Conclusions: Patients who fell were not wearing hip or head protection. Most falls were unwitnessed, and none were on 1:1 observation. Such interventions may help prevent future injurious falls.