The overlooked threat of hospital falls during the discharge period: A statewide retrospective analysis of patient safety event reports (18 August 2025)

Summary

Inpatient falls are a persistent patient safety concern and significant progress has been made in identifying prevention strategies to reduce their occurrence. A recent review of reports submitted to the Pennsylvania Patient Safety Reporting System identified a previously unknown high-risk time frame for inpatient falls: the time surrounding discharge. Event reports submitted between 1 July 2023,and 30 June 2024, revealed that falls that occurred during the discharge period were 2.5 times more likely to result in serious events compared to falls that happened at other times during the inpatient stay.

In many instances, falls that occurred on the day of discharge were associated with patients engaging in discharge-related activities, such as getting dressed, packing or gathering their belongings, showering or washing up, and getting into a vehicle. Unsupportive and ill-fitting footwear was also identified as a contributing factor to these falls. One event report also described a patient who, after falling, stated they believed they could ambulate independently because they were being discharged.

The transitional period surrounding discharge is a critical time to implement fall prevention strategies, such as assisting patients with dressing and packing; educating patients about proper footwear; and emphasizing to patients that although they are healthy enough to be discharged, they may still be at risk of falling. Targeting this time frame can help reduce the risk of serious injury from falls and ensure patients are discharged safely.

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