The Overlooked Threat of Hospital Falls During the Discharge Period: A Statewide Retrospective Analysis of Patient Safety Event Reports

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Christine E. Sanchez (chrsanchez@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority. She is responsible for utilizing patient safety data, combined with relevant literature, to develop strategies aimed at improving patient safety in Pennsylvania.

*Corresponding Author

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Rebecca Jones, director of Data Science & Research for the Patient Safety Authority, leads a multidisciplinary team advancing safety science through rigorous research, advanced data analysis, and systems-based approaches. She has authored over 40 peer-reviewed articles and served on national expert panels with organizations such as the National Quality Forum and Society to Improve Diagnosis in Medicine. A registered nurse with an MBA in healthcare management and certifications in patient safety, human factors, and risk management, she focuses on applying data-driven insights to strengthen system safety and human performance in healthcare.

Inpatient falls continue to be a patient safety challenge, with 35,450 falls reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) in 2024. While previous research has primarily focused on inpatient or post-discharge falls, the transitional period surrounding discharge has been understudied.

We queried the PA-PSRS database for fall reports submitted between July 1, 2023, and June 30, 2024. Using a stepwise refinement process, we identified a subset of falls that occurred around the time of discharge for inclusion in the falls surrounding discharge group. We used a two-proportion z-test to compare the proportion of serious events between the discharge group and the broader comparison group. We further analyzed and coded reports from the falls surrounding discharge group to identify fall type, discharge phase, injury type, discharge plan outcome, and staff presence/assistance.

A total of 253 falls surrounding discharge were identified for analysis. The proportion of serious events in this group (7.5%; 19 of 253) was significantly greater than in the comparison group (2.9%; 749 of 25,701; p<0.0001). Among the 11 identified fall types, ambulating was the most common (33.2%; 84 of 253). Over one-quarter of patients (28.5%; 72 of 253) were in the discharge complete phase when their fall occurred. Injury details were available in 185 reports, with the most common injury types being superficial skin injury (15.1%; 28 of 185), soft tissue injury (5.9%; 11 of 185), and musculoskeletal injury (5.4%; 10 of 185). Discharge plan outcome was determined in 141 reports, with the majority (80.9%; 114 of 141) indicating the discharge proceeded as planned. Information about staff presence/assistance was available in 206 reports, with over two-thirds (71.8%; 148 of 206) indicating that staff was not present when the fall occurred. Four discharge-related activities were identified and associated with falls: dressing, packing/gathering belongings, showering/washing up, and entering a vehicle.

This study identifies the time frame surrounding discharge as a critical and high-risk period for falls, representing a greater threat to patient safety than previously recognized. The significantly greater proportion of serious events in the falls surrounding discharge group compared to the broader comparison group highlights the elevated patient safety risk during this transitional period. By identifying specific discharge-related activities associated with falls, this study offers actionable insights for targeted interventions. Implementing focused strategies and integrating fall prevention into discharge planning and patient education may enhance safety and reduce the risk of serious fall-related events during this vulnerable period.

Patient falls while in the hospital, or at home following a recent hospitalization, are a well-known safety concern and the focus of many quality improvement studies and interventions. However, not much attention has been given to another high-risk period for inpatient falls: the day of and in the time surrounding discharge, before leaving the hospital. Although a patient is ready to be discharged, they may still be at risk of falling.

Taking a fresh perspective on patient falls, Patient Safety Authority researchers shine a light on the unique circumstances around hospital discharge to show that this time frame poses a greater threat to patient safety than ever considered before. Their data analysis suggests that inpatients may even be more at risk of serious events due to falls in this critical period than at other times during hospitalization. In this article, the authors identify discharge-related activities associated with patient falls (dressing, packing belongings, showering, and getting into a car) and fall prevention strategies, emphasizing the importance of maintaining vigilance throughout the discharge process until the patient has left the hospital.

injurious falls, fall-related serious events, hospital discharge, fall prevention, inpatient falls, discharge planning