A Five-Year Retrospective Study of Patient Falls in a Tertiary Hospital: Monitoring, Causes, and Impact on Patient Safety and Quality of Care

Abstract Background Falls in hospitalized patients are among the most common preventable adverse events and pose a major threat to patient safety. Despite preventive protocols, falls remain frequent and are associated with increased morbidity, prolonged hospitalization, and higher healthcare costs. Understanding the frequency, characteristics, and root causes of falls is essential to improve patient safety strategies. Aim This study aimed to examine the frequency and characteristics of inpatient falls over a five-year period and to identify their underlying causes through root cause analysis. Methods A retrospective descriptive study was conducted using hospital adverse event notification records between 2020 and 2024. A total of 211 fall incidents were identified and analyzed in terms of demographic characteristics, clinical settings, fall locations, risk scores, and root causes. The Itaki Fall Risk Scale was used to assess patient risk levels, and contributing factors were categorized into patient-related, caregiver-related, equipment-related, environmental, staff-related, and procedural causes. Results Among the 211 reported falls, the mean patient age was 50.4 ± 29.3 years, and most cases involved male patients (62.6%). The highest fall incidence was observed in 2024 (n = 78), indicating an increasing trend across the years. The majority of patients (92.4%) were classified as high risk according to the Itaki Fall Risk Scale. Most falls occurred in patient rooms (71.1%), followed by procedure/examination rooms (14.7%) and bathrooms/toilets (11.8%). Root cause analysis revealed that falls were primarily patient-related (59.7%), followed by caregiver-, equipment-, environmental-, staff-, and procedure-related factors. Conclusion Patient falls remain a significant safety concern in hospitals, with most cases occurring among high-risk patients and being preventable. Root cause analysis highlights the multifactorial nature of falls, emphasizing the need for comprehensive preventive strategies that address patient behavior, caregiver awareness, environmental safety, and staff compliance with protocols. Strengthening fall prevention programs is crucial to improving patient safety and reducing healthcare costs.