In this edition, read about research that identified a previously unknown high-risk time frame for inpatient falls: the time surrounding discharge. Also, learn about how vaccination against preventable illnesses makes communities healthier, how to protect against infant falls, and the role we all share in raising awareness of and preventing suicide.
Please share this information with your contacts to ensure everyone has the knowledge and tools to help keep safe.
New Research Shows Discharge Window as High-Risk Period for Patient Falls
Inpatient falls are a persistent patient safety concern1,2 and significant progress has been made in identifying prevention strategies to reduce their occurrence.1-11 A recent review of reports submitted to the Pennsylvania Patient Safety Reporting System identified a previously unknown high-risk time frame for inpatient falls: the time surrounding discharge.12 Event reports submitted between July 1, 2023, and June 30, 2024, revealed that falls that occurred during the discharge period were 2.5 times more likely to result in serious events compared to falls that happened at other times during the inpatient stay.
In many instances, falls that occurred on the day of discharge were associated with patients engaging in discharge-related activities, such as getting dressed, packing or gathering their belongings, showering or washing up, and getting into a vehicle. Unsupportive and ill-fitting footwear was also identified as a contributing factor to these falls. One event report also described a patient who, after falling, stated they believed they could ambulate independently because they were being discharged.
The transitional period surrounding discharge is a critical time to implement fall prevention strategies, such as assisting patients with dressing and packing; educating patients about proper footwear; and emphasizing to patients that although they are healthy enough to be discharged, they may still be at risk of falling. Targeting this time frame can help reduce the risk of serious injury from falls and ensure patients are discharged safely.
For full details and study findings, we recommend that facilities and providers review “The Overlooked Threat of Hospital Falls During the Discharge Period: A Statewide Retrospective Analysis of Patient Safety Event Reports” at doi.org/10.33940/001c.141403.
References :
- The Joint Commission. Sentinel Event Data 2023 Annual Review. The Joint Commission; 2024.
- Kepner S, Jones R. Patient Safety Trends in 2024: An Analysis of 315,418 Serious Events and Incidents From the Nation’s Largest Event Reporting Database.
Patient Safety. 2025;7(2):1339876. doi: 10.33940/001c.133876
- Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient Fall Prevention Programs as a Patient Safety Strategy: A Systematic Review.
Ann Intern Med. 2013;158:390-7. doi: https://doi.org/10.7326/0003-4819-158-5-201303051-00005.
- The Joint Commission. Sentinel Event Alert Preventing Falls and Fall-Related Injuries in Health Care Facilities. The Joint Commission. 2015(55).
- Cochran L, Foley P. Pursuing Zero Harm from Patient Falls: One Organization’s Initiatives Along the Way.
J Nurs Manag. 2022;53(11):24-33.
- Agency for Healthcare Research and Quality. Falls 2019. PSNet: Patient Safety Network. https://psnet.ahrq.gov/primer/falls#. Reviewed June 15, 2024. Accessed August 2025.
- Patient Safety & Quality Healthcare. Elevating Patient Safety Through Comprehensive Fall Prevention Strategies. PSQR. https://www.psqh.com/analysis/elevating-patient-safety-through-comprehensive-fall-prevention-strategies/. Published March 28, 2024. Accessed April 2025.
- Ganz DA, Huang C, Saliba D, et al.
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI Institute under Contract No. HHSA2902010000171TO#1). Agency for Healthcare Research and Quality; 2013.
- Dykes PC, Hurley AC. Patient-Centered Fall Prevention.
Nurs Manage. 2021;52(3):51-4. doi: 10.1097/01.NUMA.0000733668.39637.ba.
- Ganz DA, Huang C, Saliba D, et al. Which Fall Prevention Strategies Do You Want To Use? Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care (Prepared by RAND Corporation, Boston University School of Public Health, and ECRI Institute under Contract No HHSA2902010000171TO#1). Agency for Healthcare Research and Quality; 2013.
- Patient Safety Authority. Falls. PSA. https://patientsafety. pa.gov/pst/Pages/Falls/hm.aspx?t=tips. Accessed August 2025.
- Sanchez CE, Jones R. The Overlooked Threat of Hospital Falls During the Discharge Period: A Statewide Retrospective Analysis of Patient Safety Event Reports.
Patient Safety. 2025;7(2):141403. doi: 10.33940/001c.141403
Lessons From Event Reports
Bringing Awareness to Infant Falls
While reviewing high harm events, a Patient Safety Authority analyst noted a report describing the near-death of a newborn after the mother fell asleep with the baby in her arms. The event prompted the analyst to determine whether any other similar events had occurred, and what she found was shocking: dozens of reports of newborns falling across the state, every year.
Because an individual facility may only experience one or two newborn falls annually, it was virtually impossible to measure the true scope of the problem without a broader perspective.
The analysis—the largest one to date—brought light to an otherwise hidden and life-threatening issue. To further raise awareness of infant falls on a national level, the PSA collaborated with a facility to produce
a safety video about the risks and how to protect against them.
Watch and Share
Vaccination: The Shot That Saves!
Due to their lack of knowledge and understanding of vaccines, even some healthcare professionals are unable to adequately inform patients and their families about vaccination. Watch this recorded webinar to learn about the importance of vaccination for everyone and how to describe the role that vaccination plays in developing immunity, so you can discuss how community or herd immunity helps prevent diseases from spreading.
