Fall incidents are influenced by personal (e.g., physiological) and environmental (e.g., type and condition of floor) factors and can lead to multiple negative outcomes. The average healthcare cost for a fall injury (without factoring in physician services) was close to $20,0001 and continues to rise. Total direct costs for fall-related injuries for people 65 and older (i.e., expenses incurred by patients and insurance companies treatment of these injuries) are projected to reach $54.8 billion (in 2007 dollars) by the year 20202. Costs (in 2000 dollars) for nonfatal injuries were $12 billion for hospitalizations, $4 billion for emergency department visits, and $3 billion for treatment in outpatient settings. Fractures, a small part of nonfatal injuries (35%) were associated with the highest (61%) costs2. There are complexities inherent in falls research because of multiple co-acting physiological and environmental factors. While interventions for reducing and preventing falls have included physiological measures, recent efforts explore risk factors and support factors in physical settings3.

Research findings and best practices are categorized in the following table under: spatial organization (i.e., layout of the unit and the patient room), interior characteristics (particularly, flooring and furniture), sensory attributes, and environment-in-use aspects. Table 1 summarizes the main environmental features that can influence falls under each category.

Environment-related features

Spatial Organization of the Environment. Several design strategies that have been linked to fall prevention include designing layouts to maximize visibility between staff and residents in their bedrooms-along with providing easy visibility of bedrooms from the nursing station-and ensuring patients’ visual access to functional spaces (e.g., bathroom) occur within the unit. A decentralized design layout implemented at Pebble Partner Alumni Methodist Hospital/Clarian Health Partners in Indianapolis, Indiana, increased opportunities for patient observation, which contributed to a 75% reduction in falls over a five year period. Angled doorways and room layouts that provided patients with better sightlines were associated with a 6% reduction in falls4 at the Barbara Ann Karmanos Cancer Institute in Detroit, Michigan. At Pebble Partner Alumni St. Joseph Community Hospital in West Bend, Wisconin, the unit design provided a charting alcove with a window beside every bedroom to increase staff visibility to the patient (figure 1).

Proximity and access to the bathroom (e.g., a clear unobstructed pathway to the bathroom from the bed) is also a supportive factor; bathrooms placed close to the head of the bed enable easy access. Single-patient rooms incorporating headwalls designed in a cardiac critical care unit in Methodist Hospital in Indianapolis5 reduced the need to transfer patients within the unit by 90% and reduced falls from four falls/1000 patient days to two falls/1000 patient days.

Interior Characteristics of the Environment

Flooring. Floor type (carpet versus resilient), its finish (polished, high-gloss), and other properties (how absorbent or how slippery when wet) can influence falls and risk of injury from falls. Commercial-grade, low-pile, tightly woven carpet in and of itself, was not found to be a fall risk factor because it did not impact static balance. Carpeted floors are associated with fewer fall injuries than vinyl floors. Carpeting with high contrasting patterns was associated with more incidents (stumbles, reaching for handrail, veering, purposeful stepping, pausing, stopping) than carpeting with low color contrast6-these results are clearly applicable to nursing homes and assisted living facilities where 50% or more of the residents may have dementia and efforts to create a more homelike environment often include the use of carpeting. Transitions in flooring-for example, from carpeting to hard flooring surfaces-could also be a risk factor and hazards such as contact between rubber tips of canes or crutches and different types of flooring.

Furniture. The depths, heights, and sizes of furniture in the patient room may also impact its supportiveness in independent use, transfer, and daily activities, especially if it presents obstacles in circulation paths within the patient room (figure 2). Whether the chairs are armless or have arms, how far the arm extends toward the front of the chair, the seat height, seat depth, slope of the seat, etc., all can have a significant impact on a patient’s ability to rise from the chair easily (figure 3). Other risk factors include unlocked bed wheels, unstable furniture7 (e.g., medical equipment and IV poles, overbed tables that move when grasped for support), sagging bed mattress edges (increases the possibility of fall when transferring,) and shelf layouts in closets8 (having to reach high or bend low to retrieve objects).

Assistive devices. Handrails and guardrails placed strategically can prevent or reduce falls. For example, handrails on headwalls, in public areas, and in bathrooms can provide support and help in preventing falls. One benefit of the use of ceiling lifts coupled with a safe patient handling program discovered at Pebble Partner Peace Health in Springfield, Oregon, was a decrease in patient falls, skin tears, and abrasions.

Environmental features influencing falls. (Culled through research and best practices at Pebble Partners VIHA Royal Jubilee Hospital in Victoria, BC, Canada, and Paoli Hospital in Paoli, Pennsylvania.)


Environmental features identified as influencing falls

Spatial Organization

  • angled doorways

  • room layout with charting alcove

  • bathroom on headwall at rear of room to improve visibility of patient

  • sliding bathroom door to aid in access and visibility

  • toilet placed on near wall of ensuite, to reduce patients’ degree of turn before sitting on the toilet

  • toilet placed to allow both right and left handed assist; double drop down assist bars

  • doors (5′) to allow dual assist

Interior Characteristics


  • eliminate bathroom “lip” going into bedroom, which frequently causes tripping

  • material changes to allow distinct contrast between walls, cove, and floor, and between handrails and walls

  • nonslip flooring in all wet areas

  • super level floors with a maximum vertical change of r mm

  • seamless transition of flooring from pt room into hallway to eliminate any visual misperceptions


  • bed positioned within the room to allow for direct observation from hall

  • bench seating in strategic locations to allow older adults to rest on route

  • in-room storage to accommodate equipment during length of stay

  • centralized equipment depot promoting clear hallways at the unit level

  • high(est available) tech beds with night lights, exit alarms, weight sensors, rail position sensors-all wired to electronic medical records

Assistive Devices

  • handrail on headwall from bed to bathroom and all around bathroom

  • handrail walking loop within each care pod

  • handrails included in public areas, such as main entrance drop off/pick up area, route to main elevator, and each elevator lobby

Sensory Attributes

Visual environment

  • nightlight on route to bathroom

  • nightlight in bathroom shining on the toilet, with darker bathroom floor and black toilet seat, all to help highlight the toilet

  • all night lights will use amber colored bulb to illuminate but not disturb sleep

  • prescribed, even lighting levels to ensure no shadows

  • flagging systems to identify fallers and those at risk for falls

Auditory environment:

  • sound peaks might create fall risk.

  • disrupted sleep due to noise peaks may create drowsiness and fall risk.

Environment-in-use aspects

  • moving patient closer to nurse station

  • designating a room for people at risk for falls

  • footwear used

  • wet floors

Sensory attributes of the environment

Visual environment. Poor lighting affects patients’ attempts to navigate successfully in their spaces, especially at night, and has been associated with incontinence9. Increasing light levels can cause glare, another fall risk. Appropriate lighting sources (figure 4) including appropriately positioned night lights, may serve to reduce functional deficits associated with poor vision. Increasing the appropriate use of contrasts (such as between floor and wall surfaces or between the toilet and the surrounding floor/wall area) are also possible, but as yet untested empirically. Other visual interventions include instructional posters and bed signs to assist staff and caregivers in identifying those patients at risk for falls; flagging systems at hospitals10 include color coded posters, bed signs at the head of the bed, and color armbands11 on the patient.

Auditory environment. Sound peaks caused by chair and bed alarms alter the environmental experience and could be considered fall risk factors. Among older adults, demands on one’s attention for postural control and balance increase as sensory information decreases12. Postural sway is affected by reduced or inaccurate sensory information, especially when multitasking, and particularly among older adults with balance impairments who were recent fallers. Furthermore, nighttime noise peaks that disrupt sleep patterns may lead to increased drowsiness the next day, which could increase fall risk. However, no research has specifically explored the impact of various noise factors on fall rates.

Environment-in-use aspects. Interventions such as moving the patient to a room with the best visual access to nursing station13 and enabling more careful monitoring by staff, or designating a special room for high-risk fallers14, are also implemented to reduce falls. Regardless of the flooring material, persons who were shoeless had a higher risk of a fall15-8 to 11 times higher than those who were wearing athletic shoes, which have high floor-contact area. A wet floor (after an episode of incontinence) can also influence falls16, and the speed with which staff is able to clean up and dry a wet floor may impact the ongoing fall risk of patients, as well as staff and visitors.

Where do we go from here?

The environment was not the primary variable in past research but was part of a multimodal set of intrinsic and extrinsic factors-and loosely defined, if at all. Best practices continue to implement factors perceived as influential in fall prevention and reduction; many of the features reported here present hypotheses for future study. A research study has been initiated in May 2009 through The Center for Health Design’s Research Coalition to locate concrete and practical information on building design and materials that impact falls and injury from falls in healthcare settings. This project will develop an environmental assessment tool that addresses environmental issues in hospitals, specifically related to the design (as opposed to use) of the building. The tool will be pilot tested at various hospitals, including several Pebble Partners (Lake Hospital, Paoli Hospital, and the Royal Jubilee Hospital) and will be implemented in different units within hospitals to determine if there are specific environmental factors that are associated with a higher number of falls or injuries from falls. HD


  1. Rizzo J., Friedkin R., Williams C., Nabors J., Acampora D., & Tinetti M. (1998). Health Care Utilization and Costs in a Medicare Population by Fall Status. Medical Care, 36 (8), 1174-1188.
  2. Center for Disease Control and Prevention, 2009
  3. Betrabet Gulwadi G. & Calkins M. (2008). The impact of healthcare environmental design on patient falls. Concord, CA:The Center for Health Design.
  4. Livingston H. (2004).Design Matters in Health-care Facilities. And the Pebble Project has the stats to prove it. AIArchitect. April 19, 2004. accessed online January 10, 2006.
  5. Hendrich A., J. Fay, and A. Sorrells. 2004. Effects of acuity-adaptable rooms on flow of patients and delivery of care. American Journal of Critical Care 13 (1): 35-45.
  6. Perritt M., McCune E., McCune S. (2005). Research Informs design: Empirical findings suggest recommendations fir carpet pattern and texture. Alzheimer’s Care Quarterly, 6 (4). 300-305
  7. Quang Vu M., Weintraub N., Rubenstein L. (2004). Falls in the Nursing Home: Are They Preventable? Journal of the American Medical Directors Association, 6, S82-S87.
  8. Tideiksaar R. (1989). Geriatric Falls: Assessing the Cause, Preventing Recurrence. Geriatrics, 44 (7), 57-61.
  9. Klusch L. (2003). Targeting Our Approach to Incontinence. Contemporary Long Term Care, 52, 28-31.
  10. McCarter-Bayer A., Bayer F., & Hall K. (2005). Preventing Falls in Acute Care: An Innovative Approach. Journal of Gerontological Nursing, 31 (3), 25-33.
  11. Alcee D., Mather J., Jefferson P. (2000). The Experience of a Community Hospital in Quantifying and Reducing Patient Falls. Journal of Nursing Care Quality, 14, 43-53.
  12. Shumway-Cook A., & Woollacott M. (2000). Attentional Demands and Postural Control: The Effect of Sensory Context. Journal of Gerontology Medical Sciences, 55A (1), M10-M16.
  13. Mosley A., Galindo-Ciocon D., Peak N., West M. (1998). Initiation and Evaluation of a Research- Based Fall Prevention Program. Journal of Nursing Care Quality, 13 (2), 38-44.
  14. Neily J., Howard K., Quigley P., Mills P. (2005). One-Year Follow-Up After a Collaborative Breakthrough Series on Reducing Falls and Fall-Related Injuries. Journal on Quality and Patient Safety, 31 (5), 275-285.
  15. Koepsell, Wolf, Buchner, Kukull, LaCroix, Tencer, Frankenfeld, Tautvydas, and Larson (2004)
  16. Hitcho E., Krauss M., Birge S., Dunagan W., Fischer I., Johnson S., Nast P., Costantinou I., Fraser V. (2004). Characteristics and Circumstances of Falls in a Hospital Setting. Journal of General Internal Medicine, 19, 732-739.


The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at mgoodman@healthdesign.org.


If there is interest in participating in this study, please contact Carolyn Quist at cquist@healthdesign.org

Healthcare Design 2009 July;9(7):28-34