Risk Factors for Falls in Hospital In-Patients: A Prospective Nested Case Control Study

Document Type : Original Article


1 Department of Health Care Management, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

2 Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran

3 School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

4 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran


Patient falls are considered a challenge to the patient’s safety in hospitals, which, in addition to increasing the length of stay and costs, may also result in severe injuries or even the death of the patient. This study aims to investigate the associations between risk factors among fallers in comparison with the control group.
A prospective nested case control study was performed on 185 patients who fell and 1141 controls were matched with the patients at risk of fall in the same ward and during the same time. This study was conducted in a university educational hospital in Tehran with 800 beds during a 9-month period. The data included demographics, comorbidities, admission details, types of medication, clinical conditions, and activities before or during the fall. The data was collected from clinical records, hospital information system, error reporting system and observations, and the interviews with the fallers, their families and care givers (physicians, nurses, etc). Data analysis was conducted through time-based matching using a multi-level analysis.
In a multilevel model including patient-related, medication, and care-related variables, the factors that were significantly associated with an increased risk of patient falls included: longer length of stay (odds ratio [OR] = 1.01; CI = 0.32 to 0.73), using chemotherapy drugs, sedatives, anticonvulsants, benzodiazepines, and angiotensin-converting enzyme (ACE) inhibitors, visual acuity (OR = 6.93; CI = 4.22 to 11.38), balance condition (OR = 6.41; CI = 4.51 to 9.11), manual transfer aid (OR = 8.47; CI = 5.65 to 12.69), urinary incontinence (OR = 8.47, CI = 5.65 to 12.69), and cancer (OR = 2.86, CI = 1.84-4.44). These factors were found to be associating with more odds for a falling accident among patients. Several characteristics such as fall history (OR = 0.48; CI = 1.003 to 1.02), poly-pharmacy (OR = 1.37, CI = 00.85 to 2.2), stroke (OR = 0.94, CI = 0.44 to 2.02), and nurse to patient ratio (incidence rate ratio = 1.01, CI = 0.01 to 0.03) were not significantly associated with falling in hospitals.
It seems that a combination of both patient-related factors and history of medication should be considered. Moreover, modifiable clinical characteristics of patients such as vision improvement, provision of manual transfer aid, diabetes control, regular toilet program, and drug modification should be considered during the formulation of interventions.


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Hartholt KA, van der Velde N, Looman CW, et al. Trends in fall-related hospital admissions in older persons in the Netherlands. Arch Intern Med. 2010;170(10):905-911. doi:10.1001/archinternmed.2010.106
Haines TP, Hill AM, Hill KD, et al. Cost effectiveness of patient education for the prevention of falls in hospital: economic evaluation from a randomized controlled trial. BMC Med. 2013;11:135. doi:10.1186/1741-7015-11-135
Currie LM. Fall and injury prevention. Annu Rev Nurs Res. 2006;24:39-74.
Boushon B, Nielsen G, Quigley P, et al. Transforming care at the bedside how-to guide: Reducing patient injuries from falls. Cambridge, MA: Institute for Healthcare Improvement; 2008.
Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med. 2004;19(7):732-739. doi:10.1111/j.1525-1497.2004.30387.x
Chelly JE, Conroy L, Miller G, Elliott MN, Horne JL, Hudson ME. Risk factors and injury associated with falls in elderly hospitalized patients in a community hospital. J Patient Saf. 2008;4(3):178-183. doi:10.1097/PTS.0b013e3181841802
Healey F, Scobie S, Oliver D, Pryce A, Thomson R, Glampson B. Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports. Qual Saf Health Care. 2008;17(6):424-430.
Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37(2):81-87.
Morello RT, Barker AL, Watts JJ, et al. The extra resource burden of in-hospital falls: a cost of falls study. Med J Aust. 2015;203(9):367. doi:10.5694/mja15.00296
Parry SW, Steen N, Galloway SR, Kenny RA, Bond J. Falls and confidence related quality of life outcome measures in an older British cohort. Postgrad Med J. 2001;77(904):103-108.
Stevens JA. Falls among older adults--risk factors and prevention strategies. J Safety Res. 2005;36(4):409-411.
Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35 Suppl 2:ii37-ii41. doi:10.1093/ageing/afl084
Stel VS, Smit JH, Pluijm SM, Lips P. Consequences of falling in older men and women and risk factors for health service use and functional decline. Age Ageing. 2004;33(1):58-65.
Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.7326/0003-4819-158-5-201303051-00005
Gaebler S. Predicting which patient will fall again ... and again. J Adv Nurs. 1993;18(12):1895-1902.
Schwendimann R, Buhler H, De Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls prevention program. BMC Health Serv Res. 2006;6:69. doi:10.1186/1472-6963-6-69
Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Ann Intern Med. 2012;157(10):692-699. doi:10.7326/0003-4819-157-10-201211200-00005
Kwok T, Mok F, Chien WT, Tam E. Does access to bed-chair pressure sensors reduce physical restraint use in the rehabilitative care setting? J Clin Nurs. 2006;15(5):581-587. doi:10.1111/j.1365-2702.2006.01354.x
Morse JM, Black C, Oberle K, Donahue P. A prospective study to identify the fall-prone patient. Soc Sci Med. 1989;28(1):81-86.
Baek S, Piao J, Jin Y, Lee SM. Validity of the Morse Fall Scale implemented in an electronic medical record system. J Clin Nurs. 2014;23(17-18):2434-2440. doi:10.1111/jocn.12359
Iinattiniemi S, Jokelainen J, Luukinen H. Falls risk among a very old home-dwelling population. Scand J Prim Health Care. 2009;27(1):25-30. doi:10.1080/02813430802588683
Anderson C, Dolansky M, Damato EG, Jones KR. Predictors of serious fall injury in hospitalized patients. Clin Nurs Res. 2015;24(3):269-283. doi:10.1177/1054773814530758
Dunlop DD, Manheim LM, Sohn MW, Liu X, Chang RW. Incidence of functional limitation in older adults: the impact of gender, race, and chronic conditions. Arch Phys Med Rehabil. 2002;83(7):964-971.
Quigley PA, Hahm B, Collazo S, et al. Reducing serious injury from falls in two veterans' hospital medical-surgical units. J Nurs Care Qual. 2009;24(1):33-41. doi:10.1097/NCQ.0b013e31818f528e
Bradley SM, Karani R, McGinn T, Wisnivesky J. Predictors of serious injury among hospitalized patients evaluated for falls. J Hosp Med. 2010;5(2):63-68. doi:10.1002/jhm.555
Vassallo M, Vignaraja R, Sharma JC, Briggs R, Allen S. The relationship of falls to injury among hospital in-patients. Int J Clin Pract. 2005;59(1):17-20. doi:10.1111/j.1742-1241.2004.00265.x
Deandrea S, Bravi F, Turati F, Lucenteforte E, La Vecchia C, Negri E. Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Arch Gerontol Geriatr. 2013;56(3):407-415. doi:10.1016/j.archger.2012.12.006
Mayo NE, Korner-Bitensky N, Levy AR. Risk factors for fractures due to falls. Arch Phys Med Rehabil. 1993;74(9):917-921. doi:10.5555/uri:pii:000399939390267E
Wellens NI, Deschodt M, Boonen S, et al. Validity of the interRAI Acute Care based on test content: a multi-center study. Aging Clin Exp Res. 2011;23(5-6):476-486.
Healey F, Monro A, Cockram A, Adams V, Heseltine D. Using targeted risk factor reduction to prevent falls in older in-patients: a randomised controlled trial. Age Ageing. 2004;33(4):390-395. doi:10.1093/ageing/afh130
Quigley PA, Hahm B, Collazo S, et al. Reducing serious injury from falls in two veterans' hospital medical-surgical units. J Nurs Care Qual. 2009;24(1):33-41. doi:10.1097/NCQ.0b013e31818f528e
Baloh RW, Enrietto J, Jacobson KM, Lin A. Age-related changes in vestibular function: a longitudinal study. Ann N Y Acad Sci. 2001;942:210-219.
Hitcho EB, Krauss MJ, Birge S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med. 2004;19(7):732-739. doi:10.1111/j.1525-1497.2004.30387.x
Hauer K, Rost B, Rutschle K, et al. Exercise training for rehabilitation and secondary prevention of falls in geriatric patients with a history of injurious falls. J Am Geriatr Soc. 2001;49(1):10-20.
Capone LJ, Albert NM, Bena JF, Tang AS. Predictors of a fall event in hospitalized patients with cancer. Oncol Nurs Forum. 2012;39(5):E407-E415. doi:10.1188/12.onf.e407-e415
Spoelstra SL, Given BA, Schutte DL, Sikorskii A, You M, Given CW. Do older adults with cancer fall more often? A comparative analysis of falls in those with and without cancer. Oncol Nurs Forum. 2013;40(2):E69-78. doi:10.1188/13.onf.e69-e78
Klein BE, Moss SE, Klein R, Lee KE, Cruickshanks KJ. Associations of visual function with physical outcomes and limitations 5 years later in an older population: the Beaver Dam eye study. Ophthalmology. 2003;110(4):644-650. doi:10.1016/s0161-6420(02)01935-8
Patino CM, McKean-Cowdin R, Azen SP, Allison JC, Choudhury F, Varma R. Central and peripheral visual impairment and the risk of falls and falls with injury. Ophthalmology. 2010;117(2):199-206.e191. doi:10.1016/j.ophtha.2009.06.063
Leat SJ, Zecevic AA, Keeling A, Hileeto D, Labreche T, Brymer C. Prevalence of vision loss among hospital in-patients; a risk factor for falls? Ophthalmic Physiol Opt. 2018;38(1):106-114. doi:10.1111/opo.12428
Krauss MJ, Evanoff B, Hitcho E, et al. A case-control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med. 2005;20(2):116-122. doi:10.1111/j.1525-1497.2005.40171.x
Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-692. doi:10.1016/j.cger.2010.06.005
Cumming RG, Sherrington C, Lord SR, et al. Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ. 2008;336(7647):758-760. doi:10.1136/bmj.39499.546030.BE
Gluck T, Wientjes HJ, Rai GS. An evaluation of risk factors for in-patient falls in acute and rehabilitation elderly care wards. Gerontology. 1996;42(2):104-107. doi:10.1159/000213779
Salgado R, Lord SR, Packer J, Ehrlich F. Factors associated with falling in elderly hospital patients. Gerontology. 1994;40(6):325-331. doi:10.1159/000213607
Gales BJ, Menard SM. Relationship between the administration of selected medications and falls in hospitalized elderly patients. Ann Pharmacother. 1995;29(4):354-358. doi:10.1177/106002809502900402
Verwoert GC, Mattace-Raso FU, Hofman A, et al. Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study. J Am Geriatr Soc. 2008;56(10):1816-1820. doi:10.1111/j.1532-5415.2008.01946.x
Schwartz AV, Hillier TA, Sellmeyer DE, et al. Older women with diabetes have a higher risk of falls: a prospective study. Diabetes Care. 2002;25(10):1749-1754.
Berlie HD, Garwood CL. Diabetes medications related to an increased risk of falls and fall-related morbidity in the elderly. Ann Pharmacother. 2010;44(4):712-717. doi:10.1345/aph.1M551
Araki A, Ito H. Diabetes mellitus and geriatric syndromes. Geriatr Gerontol Int. 2009;9(2):105-114. doi:10.1111/j.1447-0594.2008.00495.x
Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169(21):1952-1960. doi:10.1001/archinternmed.2009.357
Shuto H, Imakyure O, Matsumoto J, et al. Medication use as a risk factor for inpatient falls in an acute care hospital: a case-crossover study. Br J Clin Pharmacol. 2010;69(5):535-542. doi:10.1111/j.1365-2125.2010.03613.x
Mion LC, Gregor S, Buettner M, Chwirchak D, Lee O, Paras W. Falls in the rehabilitation setting: incidence and characteristics. Rehabil Nurs. 1989;14(1):17-22.
Kojima T, Akishita M, Nakamura T, et al. Association of polypharmacy with fall risk among geriatric outpatients. Geriatr Gerontol Int. 2011;11(4):438-444. doi:10.1111/j.1447-0594.2011.00703.x