A five-year retrospective study of patient falls in a tertiary hospital: frequency, characteristics, and contributing factors

TL;DR

This study analyzed patient falls in a hospital over five years, finding they are common, preventable, and often linked to high-risk patients and patient-related factors.

Contribution

The study provides a detailed analysis of fall trends, contributing factors, and locations using five years of adverse event data in a tertiary hospital.

Findings

Most falls occurred in patient rooms and involved high-risk patients aged 65–80 years.

Patient-related factors like cognitive impairment and polypharmacy were the primary causes of falls.

Abstract

Falls in hospitalized patients are among the most common preventable adverse events and pose a major threat to patient safety. Despite preventive protocols, falls remain frequent and are associated with increased morbidity, prolonged hospitalization, and higher healthcare costs. Understanding the frequency, characteristics, and contributing factors of falls is essential to improve patient safety strategies.

This study aimed to examine the frequency and characteristics of inpatient falls over a five-year period and to identify conributing factors and reported causes based on adverse event notifications.

A retrospective descriptive study was conducted using hospital adverse event notification records between 2020 and 2024. A total of 211 fall incidents were identified and analyzed in terms of demographic characteristics, clinical settings, fall locations, risk scores, and root causes. The Itaki Fall Risk Scale was used to assess patient risk levels, and contributing factors were categorized into patient-related, caregiver-related, equipment-related, environmental, staff-related, and procedural causes.

Among the 211 reported falls, the mean patient age was 50.4 ± 29.3 years, and most cases involved male patients (62.6%). The highest fall incidence was observed in 2024 (n = 78), indicating an increasing trend across the years. The majority of patients (92.4%) were classified as high risk according to the Itaki Fall Risk Scale. Most falls occurred in patient rooms (71.1%), followed by procedure/examination rooms (14.7%) and bathrooms/toilets (11.8%). Analysis of perceived causes reported by staff revealed that falls were primarily patient-related (59.7%), followed by caregiver-related (33.2%), equipment-related (4.7%), environmental factors (1.4%), and rarely staff- or procedure-related factors (0.5% each).

Patient falls remain a significant safety concern in hospitals, with most cases occurring among high-risk patients and being preventable. The analysis of reported causes highlights the multifactorial nature of falls, emphasizing the need for comprehensive preventive strategies that address patient behavior, caregiver awareness, environmental safety, and staff compliance with protocols. Strengthening fall prevention programs is crucial to improving patient safety and reducing healthcare costs.

Not applicable.

This study presents a five-year period and to identify conributing factors and reported causes based on adverse event notifications of inpatient falls in a tertiary training and research hospital.

The majority of falls occurred among high-risk patients aged 65–80 years and in male patients, with most events reported in patient rooms.

Patient-related factors, including cognitive impairment, polypharmacy, and lack of compliance with preventive measures, were identified as the primary causes of falls.

Despite preventive protocols, underreporting and insufficient patient/caregiver engagement remain critical challenges in fall prevention.

Findings emphasize the importance of systematic risk assessment, patient and caregiver education, and evidence-based fall prevention strategies to strengthen patient safety culture.

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