The healthcare environment—where care is actually provided and received—has substantial effects on patient health and safety, care effectiveness, staff efficiency, and morale. The United States spends approximately 15% of its Gross National Product on healthcare, much of which is provided in hospitals (Committee on Quality of Care, 1999). Yet, despite this enormous expenditure and the available technological resources, today’s hospital care frequently runs afoul of the cardinal rule of medicine: “above all else, do no harm.” This is particularly evident in regards to patient falls.

The phenomenon of falls is a growing concern in various community, workplace, and healthcare settings. When falls occur, three important interrelated aspects demand attention: the health and physical condition of the faller, a risk of fall recurrence, and the immediate and long-term costs associated with a fall. Fall incidents are precipitated by personal (e.g., physiological) and environmental (e.g., type and condition of floor) factors.

The recently released falls study by Gowri Gulwadi, PhD, and Margaret Calkins, PhD, The Impact of Healthcare Environmental Design on Patient Falls, summarizes what we know on this major public health challenge and lays the foundation for the research that needs to be done to reduce patient falls.

Falls in healthcare settings are a frequent occurrence, with the benchmark for patient falls in hospitals at 3.1 per 1000 patient days and having significant negative outcomes for fallers. In 2005, there were 1.8 million fall-related nonfatal injuries (e.g., fractures, traumas) that were severe enough to seek medical attention, while in 2003, there were 13,820 fall-related fatalities among people 65 years and older. Approximately 10% (or 180,000) of these fall-related injuries occurred in healthcare institutions. The average healthcare cost for a fall injury (without factoring in physician services) was close to $20,000 and continues to rise. The direct costs for fall-related injuries in the United States for people 65 and older are projected to reach $43.8 billion by the year 2020 of which at least $3.6 billion would be associated with falls occurring within a healthcare setting.

Underreporting and inconsistencies in reporting are complicated by multiple definitions of falls both in literature and in hospital and nursing home incident reports. Further, falls are typically unanticipated events, and, thus, are seldom directly observed. As such, the physical environment is an often-overlooked factor that can serve either to increase risk or mitigate risk. For instance, there is clear evidence that older individuals fall more often than their younger counterparts. Brandis studied 207 falls in an inpatient unit and found that people over the age of 80 accounted for 40% of the falls, and 77% of the falls occurred in people aged 60 and older. Thus, this report could have been organized by age of cohort groups.

Fall risk is clearly a multimodal function. Examples of studies that the authors cite:

  • If a person is weak, he or she may fall while trying to get up from bed, even if there is a bedrail

  • A loose rug or deep threshold at a doorway may cause a fully healthy and ambulatory individual to trip and fall

  • Single, acuity-adaptable patient rooms seem to reduce falls (75% reduction) by reducing the number of patient transfers (Methodist Hospital/Clarian Health Partners Hospital)

  • Carpeting with high-contrasting patterns was associated (p < 0.0001) with more fall incidents (i.e., stumbles, veering, etc.) than carpeting with low color contrast

  • A patient who could not rise from a chair by himself was more than 10 times more likely to fall than the unimpaired patient

  • Patients who were shoeless had an 8 to 11 times higher risk than those who were wearing athletic shoes, with high floor-contact area

Most often, it is a combination of factors that leads to a fall. Environmental factors ranging from lighting levels to type of flooring are significant fall risk factors and can be relatively easily manipulated to create fall-prevention and injury-reduction design interventions. However, the first step in developing environmental design interventions is to find evidence-based environmental correlates of falls. The paper presents the findings from a review of 171 fall-related articles, specifically focusing on environmental factors that were empirically studied, mentioned, or recommended in each article. To further discern the validity and clarity of the environment-related information from each article, a four-tier rating system was used to provide an easy method for readers to ascertain the level of confidence they should place in the information.

Information was categorized according to four environmental factors that emerged as common across healthcare populations and settings: spatial organization, interior characteristics, sensory attributes, and use of environment. While the quality of some of the information reviewed is well-grounded, much of it requires interpolation or further study because specific characteristics of the physical environment are either poorly articulated or missing altogether. Recognizing that widening the perspective will better define the role of environmental factors in fall detection and prevention, this cutting-edge report explores the environmental correlates of falls in healthcare settings and recommends compelling guidance on the falls research roadmap of the future.

Conclusions and directions for future research

The authors came to the following conclusions: the first step in implementing fall-detection and targeted-fall- and injury-prevention measures among patients occurs when staff is able to identify those patients at risk for falls. While the report endorses a well-designed, fall-risk-assessment tool, the process of recording and documenting fall risk factors and later monitoring the use of fall-prevention measures can be influenced by spatial characteristics on the medical unit.

Clustering the patients according to need and placing frequent fallers in patient rooms that are close together, for example, might enable a better fit between staffing needs and patient needs, especially because risk-management procedures typically include frequent monitoring of patients. New design features such as decentralized nurses’ stations, better visual access, and same-handed and acuity-adaptable rooms highlight design improvements that could assist both staff and residents in fall-prevention measures. In addition, the systematic examination of fall-related patterns, such as a higher number of fall incidents when getting out of bed at night to go to the bathroom, can point to targeted environmental interventions (e.g., better night lights and more accessible call bells).

Mostly existing as expert design recommendations, interior environment factors such as flooring and furniture continue to appear in fall-prevention material that is disseminated to providers without much solid evidence of their efficacy. More research is needed on lighting and sound levels, and their effect on sleep disruption patterns and next-day functioning of cognitively intact and cognitively impaired persons in healthcare environments. Multiple factors might interact with environmental factors to contribute to higher nocturnal fall rates—staffing ratios, incontinence, disrupted sleep, subdued lighting, etc. More research is needed to offer a nuanced approach to these factors.

Much progress has occurred in flagging systems on patient units, some are less obtrusive than others. While some flagging systems such as the green posters and bed signs serve caregiver needs, others are meant to be cues for the patient (for example, a poster reminding him or her to call for assistance if needed). The level of obtrusiveness, its coexistence with other necessary cues in the environment meant for patients, and its effect on psychosocial factors among residents/patients and their caregivers, remains to be investigated.

The influence of individual versus shared-room occupancies on fall risk factors has not been studied. Private rooms have been implicated both as a supportive factor—because families are more likely to spend more time visiting in a private room and, therefore, are available to provide assistance—and as a risk factor—because there is no roommate to remind an at-risk individual to call for assistance. Because most of the research is multimodal in nature, it is difficult to know the exact contribution environmental factors play in reducing falls and injury from falls. Further, environmental factors are broadly and loosely defined in the research literature.

The falls study, funded by The Center for Health Design, is a superb and practical study and should be required reading for all healthcare designers and architects, as well as all clinicians. Using the empirical information from this report, supplemented by expert knowledge where there is insufficient empirical evidence, a searchable database would be an excellent next step that would benefit the healthcare industry. There is much work to be done in terms of falls research—this report offers an organizing framework within which to situate future empirical efforts. I encourage you to read the full report at The Center’s Web site, HD

Paul Barach, BSc, MD, MPH, Maj (ret.), is Professor, University of South Florida, Tampa, and University of Utrecht Medical Center, Netherlands, and is Chair of the CHD Research Council.

For more information and to read the full report, visit

Healthcare Design 2008 November;8(11):64-70