Patient falls are the most frequently reported incident in most senior living and community based care settings, according to the Centers for Disease Control and Prevention. Researchers say more than one out of four people age 65 and older fall each year, but less than half tell their doctors. It has also been found that falling once doubles a patient’s chance of falling again. Most falls are caused by a combination of risk factors and the more risk factors, the greater the chances of falling.

Given the knowledge that your patient population is at risk for falls, what are you doing as an organization to analyze your incident reports on an ongoing basis in order to limit the frequency and severity of patient falls?

Incident report tool

A good first step is to evaluate your incident reporting policy/procedure. Does your policy/procedure include a clear definition of what constitutes a reportable fall incident?  A clear definition will provide guidance to the staff, so that reporting is consistent across the organization, and the aggregate numbers are more reliable.

Next, evaluate the report form that is utilized to document fall incidents. Is there one “catchall” tool used for any type of incident, or does the organization use a specific tool for patient/resident falls? The more information and details related to the fall that are collected, the more valuable the trending and analysis data will be. 

As an example, a comprehensive tool (the Post Fall Investigation Tool) developed by the Patient Safety Authority of the Commonwealth of Pennsylvania, collects information related to numerous factors. This includes information related to prior fall risk assessments, location of fall, activity at time of fall, medications and toileting. This information can be “aggregated over time to assist fall teams in identifying common intrinsic and extrinsic risk factors for falls and potential root causes.”

Trending & analysis

The collection of detailed, patient/resident specific information can be valuable in terms of adjustments to the individual plan of care and decisions to provide assistive devices such as canes, walkers, shower chairs, etc. However, there is additional value in analyzing aggregated fall data. Detailed trending and analysis of all reported fall incidents may lead to improvements in the organization-wide fall prevention program and overall patient/resident safety.

As part of the fall review process, evaluate whether standard fall-prevention interventions were in place at the time of the fall. These may include: bed locked in low position with rails up, call light, assistive devices and personal items within the patient’s reach, nonslip patient footwear, clutter-free room and adequate lighting, patient and family education, and evidence of regular rounding.


The average cost of a fall with injury to both the patient/resident and the organization is $14,000. However, recent advances in technology have allowed for potential cost mitigation. Some of the advances now available to the health care industry include motion based monitoring, virtual sitter technology and real-time video monitoring. Consider establishing an ongoing process for evaluating new technology to help reduce the incidence and severity of falls.

It is important that all healthcare organizations take a closer look at what they are doing to report, investigate and analyze patient/resident falls. A proactive approach can lead to a reduction in falls along with a reduction in serious injuries. This is an important goal in any Patient Safety and Performance Improvement Program.

Betty Norman is the Director of Risk Control Services GHP at Glatfelter Insurance Group.