Released in 2000, the landmark report “To Err is Human” aimed to transform patient safety by highlighting the prevalence of medical errors and their devastating impact. The report underscored various issues, including medication errors, falls, and surgical complications, garnering widespread attention and spurring significant improvements in certain areas of patient safety. As a result of this increased focus, tools like the World Health Organization’s Surgical Safety Checklist have decreased surgical complications and deaths, while electronic health records and barcode medication administration systems have significantly reduced medication errors.
The persistent challenge of falls: a two-decade struggle
Despite advancements in certain aspects of patient safety, the persistent challenge of falls in health care settings remains largely unresolved more than two decades later. In fact, there is evidence that the situation may have worsened. The mortality rate from falls among older Americans has more than tripled in the past 20 years, with over 36,500 individuals aged 65 and older having falls recorded as the underlying cause of death compared to approximately 10,100 deaths in 1999.
Even policy interventions, such as the Centers for Medicare & Medicaid Services (CMS) decision in 2008 to cease reimbursement for fall-related injuries in hospitals, have failed to significantly reduce fall incidence. While studies have shown some improvements in the implementation of fall prevention practices following this policy change, there has been no consistent or substantial decrease in the overall occurrence of falls in hospital settings.
It appears that the health care industry has inadvertently settled into a state of complacency regarding falls, unlike its approach to other safety issues. Rather than systematically addressing falls with the same rigor and innovation applied to other patient safety concerns, there seems to be a tacit acceptance of falls as an inevitable aspect of hospital care. This passive stance not only undermines ongoing efforts to enhance overall patient safety but also diminishes the urgency to prevent these potentially life-threatening incidents.
The human and financial cost of falls
Every one of us has a stake in this issue, and the ‘why’ is clear and worth reiterating. Every year in the United States, up to 1 million patients fall in hospitals, with a quarter of these falls resulting in injuries. Alarmingly, 11,000 of these patients die as a direct consequence of their falls. Beyond the immediate physical injuries, falls can trigger a cascade of negative outcomes. They can lead to prolonged hospital stays, increased risk of infections, reduced mobility, and a loss of independence. For elderly patients, in particular, a fall can mark the beginning of a rapid decline in overall health and quality of life.
The costs of falls are staggering. According to the Centers for Disease Control and Prevention (CDC), falls cost an estimated $50 billion annually in the United States. On an individual level, the total cost per patient for a fall averages $62,000. This financial burden extends far beyond the immediate medical expenses. For hospitals, falls can lead to increased liability, higher insurance premiums, diminished community reputation, and potential litigation.
Plus, the rate of falls is poised to escalate in the coming years due to demographic shifts. As the baby boomer generation ages, the proportion of elderly patients–who are at higher risk for falls–will increase significantly. By 2030, baby boomers will be 65 or older, meaning one in every five Americans will be of retirement age according to the current guidelines. This demographic tsunami will place unprecedented pressure on health care systems, potentially exacerbating the already significant problem of in-hospital falls.
As hospitals continue to grapple with the financial aftermath of the COVID-19 pandemic, they need to think innovatively about ways to enhance operational efficiency while improving patient care. This calls for a data-driven approach to guide our decisions and strategies. Interestingly, the evidence suggests we may need to rethink our standard fall-prevention approaches. A closer look at the data reveals some surprising insights about many widely adopted fall-prevention strategies.
The evidence gap in fall prevention strategies
Despite the widespread adoption of various fall-prevention strategies, many lack the robust evidence base necessary to justify their use. The lack of strong results may explain the persistently high rate of falls in health care settings.
Take, for example, the use of bed alarms. While some studies suggest that bed alarms can contribute to fall reduction when integrated into a comprehensive prevention program, others indicate that these devices, when used in isolation, fail to significantly decrease fall incidents. Moreover, the constant alerts from these alarms may inadvertently contribute to alarm fatigue among staff, potentially leading to delayed responses or even overlooked warnings.
The use of physical restraints is another fall prevention strategy that lacks robust supporting evidence. Contrary to their intended purpose, studies have found that restraints do not decrease the risk of falls and may cause agitation, confusion, and physical weakness in patients, potentially leading to more frequent risky behaviors that lead to falls. Moreover, when falls do occur in restrained patients, the resulting injuries tend to be more severe than those sustained by unrestrained individuals.
Perhaps most surprising is the mixed efficacy of in-person sitters, a practice that incurs significant costs for hospitals. Despite the substantial financial investment—often amounting to millions of dollars annually in staffing expenses—the use of sitters yields conflicting results in terms of fall prevention. This inconsistency is particularly concerning given the high cost of implementation. In a health care industry strapped by workforce shortages, including the availability of dedicated in-person sitters, this practice can further stress staffing on a unit as clinical personnel are often assigned to 1:1 sitting, leaving the remaining staff to absorb additional work.
Technology meets human expertise
While many traditional fall prevention strategies lack robust evidence, there are approaches that have demonstrated efficacy through rigorous studies. Tried and tested strategies backed by evidence include removing environmental risk factors, such as clutter in walkways and loose rugs, as well as utilizing assistive devices like walkers. These interventions have consistently shown positive results in reducing fall incidents across various health care settings.
In addition to these established methods, virtual patient monitoring systems have emerged as one of the most promising solutions in fall prevention, consistently decreasing falls while simultaneously reducing the cost associated with in-person sitters. While results vary considerably across different health care settings, reported fall reductions range from 35 percent to as high as 100 percent in some cases. This significant reduction in falls directly translates to substantial cost savings for health care facilities. One notable study reported a 47.1 percent decrease in sitter costs after implementing virtual monitoring, which for many hospitals amounts to millions of dollars in annual savings.
It’s interesting that virtual monitoring systems consistently demonstrate significant reductions in fall rates while in-person sitters yield conflicting results despite their high costs. This disparity likely stems from the unique advantages of technology. The combination of technology and human expertise results in the best of both worlds: the tireless vigilance and data processing capabilities of technology, coupled with human judgment and intervention when needed. Engaged virtual observers who proactively develop a supportive relationship with the patients they monitor can effectively redirect potentially harmful behaviors. The human element of virtual observation is a powerful deterrent to avoidable patient harm.
Unlike in-person sitters who can only monitor one patient at a time, a single remote observer can effectively oversee multiple patients simultaneously, increasing efficiency without compromising care quality. Additionally, the integration of AI helps identify subtle behavioral changes or risk factors that might escape human notice, enabling more proactive and precise interventions.
However, it’s crucial to recognize that these technologies are not standalone solutions. Studies consistently show that virtual observation technology is most effective when integrated with traditional fall prevention strategies. This comprehensive approach combines the strengths of both innovative and established methods, creating a more robust safety net for patients.
Renewing our commitment to patient safety
As health care leaders, we must heed the call to action articulated by organizations like Press Ganey and recommit ourselves to patient safety. It’s time to shake off the complacency that has settled around the issue of falls and once again turn to data-driven solutions to address this persistent problem. We need to foster a culture of continuous improvement, where we constantly evaluate our practices and embrace evidence-based innovations.
This isn’t just about statistics or cost savings. It’s about real people—our family members, our friends, our neighbors, and potentially ourselves. Every fall prevented is a life potentially saved or a devastating injury averted. By combining the best of human care with cutting-edge technology, we have the opportunity to significantly reduce fall rates and improve patient outcomes and quality of life. It’s time to renew our commitment to this critical aspect of patient safety and take decisive action to create safer health care environments for all.
Christine Gall is a nurse executive.
