With healthcare facilities scrambling to improve their financial and performance position under the Affordable Care Act (ACA), there’s been renewed focus on falls as a preventable occurrence. Hospital-associated injuries from falls are considered a “never event” by the National Quality Forum (NQF) and the Centers for Medicare & Medicaid Services (CMS), and organizations are no longer reimbursed by Medicaid for these accidents. Falls most often occur in transfers from the bed to bath area, and they’re often associated with toileting activities. However, falls are also reported in diagnostic and treatment (ED, radiology) and ancillary locations. The Joint Commission regularly details voluntarily reported root cause analyses of sentinel events—those resulting in death or permanent loss of function. Falls have one of the highest incidences of physical environment root causes. According to Joint Commission data for 2004 through the second quarter of 2012, the physical environment contributes to falls in 39 percent of reported fall events.


A multifaceted approach

Identifying patient demographics (such as age) and other known risks for falls (such as a prior fall) are primary components of any patient falls program, but successful fall prevention initiatives should include education of staff, patients, and families; operational policies (one or more of many types of patient risk assessments); reporting and tracking to better understand root causes; and interventions that often include a bundle of built environment features that may range from unit layout (ensuring patient visibility) to equipment use (bedrails). Ways to reduce falls may also be implemented sequentially—certain aspects for low-risk populations, with additional interventions considered as risk increases. Additionally, some factors differ between patient types, so methods for the prevention, detection, and treatment may need to be established on a unit-by-unit basis.

In several studies, results indicated that certain groups might be at higher risk. For example, in 2007, Efriam Aizen, et al., published a study conducted in a geriatric rehabilitation setting where activity contributing to falls was especially common among stroke patients and hip surgery patients, due to a lack of understanding of their own capabilities. A 1998 study by Katherine Ash and colleagues reported that the highest rate of falls occurred in neuroscience and geriatric assessment units. A 1993 research brief by Beverly Roberts found that patients who transferred out of an ICU to other units also had a higher rate of falls—three times higher than those who had not been in an ICU. These studies highlight the need for organizations to evaluate their own historical data whenever possible to ascertain all conditions that may contribute to falls.


Design categories and considerations

Numerous recent literature reviews summarize both the intrinsic issues (the patient’s medical condition) and extrinsic issues (the built environment) associated with falls in healthcare environments. Unfortunately, in many published studies where the environment is referenced,  there’s no supporting detail to describe the effect of specific conditions (for example, lighting level or bathroom visibility and distance). This is an inherent challenge associated with a “live” environment, where it’s often not feasible to experiment with specific isolated conditions. Individual factors are often evaluated in laboratory settings that may not capture the complexity of patients interacting with their surroundings. Overall, the design condition that’s been most studied in hospitals is flooring material. This is sometimes possible when a facility conducts a renovation and can compare one floor condition to another. However, these studies provide mixed results and point to the need to consider subflooring characteristics, as well.

As many programs incorporate a bundled approach (a combination of lighting, flooring, patient education, signage, footwear, timed toileting, and regular patient screening for risk), most studies report on the types of considerations in place at the time of the study. As a result, the bundles often associated with fall mitigation programs become the standard of care (placing the call bell within the patient’s reach, placing the bed rails raised, and keeping the bed at the lowest position). This approach can be effective, but indicates the need for a systems approach to operational and design considerations—there’s no “silver bullet” to solve the problem. Lastly, while some prevention programs don’t show a significant reduction in falls due to study protocol challenges, some result in a reduction of falls with injury—another key metric for organizations to consider. For example, in a 2009 study, Anna Barker, et al., found the rate of falls varied over the course of the study, with no significant change in the rate before and after the falls program was implemented. She speculates this may be explained by improved reporting throughout the observation period. However, over the course of the observation period, the reduction in fall injuries was substantial and sustained.

Numerous features of the built environment should be considered in combination to reduce the risk of falls. By creating a framework of the underlying conditions associated with a fall (for example, visibility), types of solutions can be identified based on project scope (unit configuration for a new project versus installation of grab rails in an existing unit). A slightly more detailed list includes:

Building envelope

  • Entrance canopies to protect the entry from weather
  • Walk-off mats large enough to cover the width of the door and capture several steps after entering the building

Unit configuration

  • Unit shape to allow visibility and accessibility of all patient rooms
  • Charting areas and nurses’ stations with visibility to patient rooms, supplemented by technology when needed (video surveillance)

Room configuration and layout

  • Bathroom sized for the patient, equipment (IV pole), and a caregiver providing assistance
  • Space for the family provided to facilitate assistance with patient mobility
  • Grab bars positioned to provide adequate support for patients
  • Bathroom located in proximity to the bed
  • Bathroom visible (open door) from the bed


  • No abrupt changes in light levels
  • Low-level lighting available in nighttime/dark conditions
  • Path to the patient bathroom visible at night

Furniture, fixtures, and equipment (FF&E)           

  • Low-height bed positions and brakes
  • Bed/chair alarms to alert staff to potential exit and fall risk
  • Bedrail/restraint use minimized
  • Adequate storage provided to eliminate clutter
  • Correct toilet height
  • Space for a bedside commode, if needed
  • Adjustable furniture seat height to suit varying patient types
  • Call buttons within easy reach of the bed
  • Grab rails provided to facilitate ambulation in paths of travel
  • Mobility aids (walkers) within reach of the patient bed/chair
  • Visual cues (signs, etc.) posted in highly visible locations to alert staff to high-risk patients

Interior finishes

  • Floors protected from spills/wet conditions (nonslip materials, gel dispenser catches)
  • Bedside nonslip mats to mitiga
    te the risk of falls for high-risk patients
  • Flooring and subflooring materials selected to mitigate injury
  • Walking surfaces clear from irregularities (loose rugs/mats, height/material changes)
  • Paths of travel clearly visible (not confused by patterns, glare, obstructions).

The cost of a fall

With questions surrounding reimbursement, it’s important to understand the cost implications falls have to organizations. In a published 2011 study, Catherine Wong, et al., conducted an analysis for an initiative to minimize falls with injury. The analysis included the cost and length of stay attributable to serious fall injury at three hospitals in a Midwest healthcare system. Multivariate analyses indicated that operational costs for falls resulting in serious injury, as compared with controls, were $13,316 more and that patients stayed 6.3 days longer than those who didn’t fall. In another 2011 study by John Galbraith, et al., researchers found 85 falls occurred in the 12 months prior to a falls prevention intervention program and identified that 15.3 percent of those falls resulted in minor injuries and 9.4 percent resulted in major injuries. The total cost incurred during this 12-month pre-prevention period as a result of falls was $117,754 (most as a result of hip fracture). In a 12-month post-intervention period, the total costs accrued as a result of falls was $812.


Participating in the solution

Improving safety depends on interaction between people (patients, families, and staff), operations, and the environment. With an increasing focus on the ACA and quality linked to reimbursement, evaluating the intrinsic and extrinsic conditions that contribute to falls is paramount. While architects and designers can’t affect the condition of the patient, or institute operational procedures and policies, they can help educate care providers and facility managers about the role the environment plays in a systems approach to reducing falls and falls with injury. Without undergoing a building project, changes to unit design are typically not a feasible option for a falls-prevention program and, therefore, design considerations may not be an area of understanding for the client.

Designers also have the opportunity to present themselves as educated problem-solvers, with awareness of the many issues (beyond design) that can contribute to this complex problem. Designers should be asking about existing fall rates, any trends that have been identified related to the causes of falls, and any programs that have been put in place. This can open the conversation to the right solutions to address a client’s specific problems. Discussing these issues in the context of desired patient care and outcomes can help bridge the gap between design and operations, and research and reality.


More fall-prevention resources

A falls calculator created by the Pennsylvania Patient Authority allows organizations to calculate their own costs and provides default values, based on state-wide 2012 data, if facility-specific data isn’t available. The calculator can be found at here.

  • A research paper authored by Maggie Calkins, Stacey Biddle, and Orion Biesan in 2012 provides a good summary of the issues, and reports cross-sectional analysis of 27 units in 12 hospitals using archival fall data to a number of design characteristics that were associated with greater or fewer falls. The paper includes a newly developed facility evaluation tool, the Falls Environment Evaluation Tool (FEET).
  • Another recent tool published by The Center for Health Design focuses on flooring and includes implications for falls. Click here to view.

Ellen Taylor, AIA, MBA, EDAC, is an architect and built environment researcher, serving as the director of Pebble Projects for The Center for Health Design in Concord, Calif. She can be reached at etaylor@healthdesign.org.