Patient Safety

Hundreds of thousands of patients fall in hospitals every year. Between 30 to 35 percent of patients who fall sustain an injury. Each of these injuries, on average, add 6.3 days to the hospital stay. Cost for a fall with injury is about $14,056. Falls have been identified by the Centers for Medicare & Medicaid Services (CMS) as an event that is preventable and should never occur. CMS has also identified “falls and trauma” on its list of Hospital Acquired Conditions for which reimbursement will be limited, specifically for falls that result in fractures, dislocations and intracranial injuries. Hundreds of thousands of patients fall in hospitals every year. (Sources available on request)

Project Team

The Joint Commission Center for Transforming Healthcare worked with seven participating organizations across the country to undertake a project to prevent falls that occur in health care facilities and result in injury to patients. All project teams used Robust Process Improvement® (RPI®) to identify causes and develop solutions to prevent patient falls. RPI is a fact-based, systematic, and data-driven problem-solving methodology that incorporates tools and concepts from Lean Six Sigma and change management. The methodology and solutions were then tested, validated, and spread to other organizations through a pilot project with additional hospitals that did not have Lean Six Sigma expertise.

Project Team
Barnes-Jewish Hospital, Missouri
Baylor Health System, Texas
Fairview Health Services, Minnesota
Kaiser Permanente, California
Memorial Hermann Healthcare System, Texas
Wake Forest Baptist Medical Center, North Carolina
Wentworth-Douglass Hospital, New Hampshire

Pilot Team
Memorial Hermann North West Hospital, Memorial Hermann Health System, Texas
Memorial Hermann Katy Hospital, Memorial Hermann Health System, Texas
Memorial Hermann Sugarland Hospital, Memorial Hermann Health System, Texas
Doctor’s Hospital, Baptist Health System, Florida
Baptist Medical Center, Baptist Healthcare Network, New York

Project Results

Five organizations submitted data throughout the project timeline. In aggregate, the five organizations demonstrated:

  • A 62% reduction in the overall falls with injury rate.
  • A 35% reduction in the overall falls rate.
  • A typical 200-bed hospital that used this robust process improvement approach to reduce patient falls with injury, could expect 72 fewer injuries and $1 million in costs avoided.
  • A typical 400-bed hospital could expect 134 fewer injuries and $1.9 million in costs avoided. 

The additional hospitals that tested the original methodology and solutions had similar results.

Our Preventing Falls Targeted Solutions Tool

The Center’s Preventing Falls Targeted Solutions Tool® (TST®) is an innovative web-based application designed to help health care organizations understand the reasons why patients fall and implement evidence-based solutions that can help prevent them.

Additional Resources

The following additional resources are available for the Preventing Falls project: