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New Guidelines for Helping Prevent Patient Falls

Preventing patient falls is always a hot topic, especially at hospitals. A CDC fact sheet says one out of three older persons fall each year and one of every five falls causes a serious injury, such as fractures and head injuries. When patients fall in the hospital, it is not only a patient safety or risk issue but often a financial issue.

CMS has identified hospital-acquired conditions as instances in which there is no additional payment from Medicare. For instance, if a Medicare patient falls and suffers a subdural hematoma, is in intensive care for four days and then dies, the hospital will not be reimbursed for expenses related to the fall.

The Joint Commission wants hospitals and healthcare facilities to pay more attention to falls. TJC notes that 30-50% of all falls result in an injury. The JC recently issued Sentinel Event Alert 55 on preventing falls and fall-related injuries in healthcare facilities. Elderly patients are not the only ones at risk. Patients of any age can fall due to medications, surgery, procedures, or diagnostic testing that can leave them in a weakened or confused condition.

TJC recently published a targeted-solution tool for preventing falls. Falls, on average, add 6.3 days to the length of stay and cost about $14,056. The hospitals in the pilot had impressive results in using the tool which reduced falls by 35% and fall injuries by 62%. The targeted solution tool is complimentary to TJC accredited organizations. However, staff at every hospital and healthcare facility should read the JC documents on falls and implement any recommendations not currently being followed.

The most common contributing factors to falls are inadequate assessment, communication failures, lack of adherence to policies and safety practices and inadequate staffing or staff orientation. TJC data published July 9 states that from 2004 to the present, there were 750 falls with 91 being reported in 2014, making falls the second most frequent sentinel event in 2014. It was the fifth most common one in 2013 and the sixth in 2012.

To prevent falls:

  • Assess staffing to ensure there are enough employees to prevent falls.
  • Use preventive equipment such as alarms.
  • Have an educated and interdisciplinary falls committee.
  • Use a validated tool to assess the risk for falls such as the Morse Fall Scale or Hendrich II.
  • Standardize hand-off communications when giving reports.
  • Individualize the patient plan of care.
  • Conduct post-fall management that includes a post-fall huddle.

Other initiatives to minimize falls:

  • Regular analysis of medications.
  • Safe room set up, toileting, hourly rounding, and safety signage.
  • Identification of high-risk patients with bracelets or visual clues like blankets, socks or signage on the door or over the bed.
  • Creation of no-pass zones in which anyone who can see the call light must respond whether it is their patient or not.
  • Creation of a personalized recorded message added to the call light.


  • “CDC Important Facts about Falls” is available here.
  • More information from CMS on hospital-acquired conditions can be read here.
  • TJC Sentinel Event Alert 55: Preventing falls and fall-related injuries in health care facilities, issued September 28, is here.
  • More information about the JC’s new targeted solutions for preventing falls is available here.

Related Webinar: Give Falls the Slip: TJC & CMS Hospital CoPs & Standards

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