Falls and fall-related injuries are common worldwide and have the heaviest impact in low-income communities and communal settings with a preponderance of older adults. Falls can cause severe injury such as hip fractures and head trauma. Among older adults, injurious falls may heighten the risk for further loss of mobility and early death. The World Health Organization estimates that 37.3 million falls severe enough to require medical attention occur each year and notes that falls are the second leading cause of unintentional injury deaths worldwide, after road traffic injuries [7]. Because the number of falls is so high, the resultant loss of disability-adjusted life years (DALYs) is significant—more lives lived with disability than results from transport injury, drowning, burns, and poisoning combined [7]. Not only is the individual economic burden related to falls and fall injuries increasing, healthcare system costs have skyrocketed. Approximately 40% of the total DALYs lost due to falls globally occurs in children [7].

Falls and fall-related injuries are common worldwide and have the heaviest impact in low-income communities and communal settings with a preponderance of older adults. Falls can cause severe injury such as hip fractures and head trauma. Among older adults, injurious falls may heighten the risk for further loss of mobility and early death. The World Health Organization estimates that 37.3 million falls severe enough to require medical attention occur each year and notes that falls are the second leading cause of unintentional injury deaths worldwide, after road traffic injuries [7]. Because the number of falls is so high, the resultant loss of disability-adjusted life years (DALYs) is significant—more lives lived with disability than results from transport injury, drowning, burns, and poisoning combined [7]. Not only is the individual economic burden related to falls and fall injuries increasing, healthcare system costs have skyrocketed. Approximately 40% of the total DALYs lost due to falls globally occurs in children [7].

As noted, falls are a common occurrence in the frail older adult population, causing injuries that may result in disability, institutionalization (e.g., long-term care facility admission), or even death. Older adults are particularly prone to falling because of age-associated, gradual onset of lower body muscle weakness, disturbances of gait, and balance deficits. More than 14 million, or 1 in 4, older adults in the United States report falling every year. About 30% of falls result in injury severe enough to require medical attention; of these, approximately 50% require treatment for bone fracture. The most common skeletal fracture sites are the hip, spine, forearm, leg, pelvis, arm, and hand. Hip fractures from falling occur at the rate of about 1 per 100 falls in older adults, a serious complication that requires hospitalization, surgery, and often results in long-term disability. Even in the absence of injury, many older people who fall then develop a fear of falling, which may prompt additional restriction of physical activity, leading to further loss of physical fitness and agility, thereby increasing the risk of falling.

Among those 19 years of age or younger, falls are the most common cause of nonfatal injuries each year. Children younger than 6 years of age have the highest proportion of visits for falls, with 1.2 million emergency department visits per year [13]. Falls threaten the safety of children, and they are fourth among causes of unintentional death in children and adolescents. There is concern that childhood falls are under-reported events in health institutions [27].

Falls are defined by the World Health Organization as "events that result in a person coming to rest inadvertently on the ground, floor, or other lower level" [7]. Falls can be categorized into three types: physiological anticipated, physiological unanticipated, and accidental. It is important that the types of falls and risks of falling, whether living at home or residing in healthcare facilities, are well understood so appropriate fall prevention measures can be undertaken [9]. Fall prevention strategies designed for community-dwelling persons and healthcare facility inpatients and residents will be discussed later in this course.

The Joint Commission (TJC) published a sentinel event alert to assist in preventing falls and fall-related injuries in healthcare settings. A sentinel event is "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" [10]. Falls resulting in serious injury or death are among the top 10 sentinel events reported to TJC. Of the 465 falls reported to TJC between 2009 and 2015, 63% resulted in death, while the remaining 37% resulted in injuries only [11].

Reimbursement to hospitals and long-term care facility for costs related to fall injuries is no longer covered by the Centers for Medicare and Medicaid Services (CMS) as of 2008 [16]. However, CMS does reimburse for fall risk assessments and fall prevention programs. Falls were not originally included in the CMS no-pay policy, and the addition of falls to the policy was originally questioned due to lack of supporting evidence of fall prevention efficacy. However, the decision was made to add falls to the no-pay policy in hopes of increasing research efforts to further prevent falls. The CMS has stated, "…we believe these types of injuries and trauma should not occur in the hospital, and we look forward to…identifying research…that will assist hospitals in following the appropriate steps to prevent these conditions from occurring after admission" [17].

Personal fall risks can be organized into two categories: those associated with environmental (extrinsic) hazards and those related to age, general health, and mobility (intrinsic factors). Extrinsic factors include poor lighting, lack of personal ambulation aids (if needed), loose carpets, slippery floors, low objects (e.g., low toilets), steps, cords, or improper footwear. Intrinsic factors are those associated with aging, intoxication, and/or chronic disease, such as weakness, disturbances of gait and balance, declining vision, and medication side effects. Examples of intrinsic factors that lead to an increased risk of falling are gait abnormalities associated with Parkinson or vestibular diseases; bradycardia from beta blockers; drowsiness associated with sedative medication; reduced visual acuity from retinopathy or cataracts; hypotension (postural, medication induced, or hypovolemic); delirium and orthostatic instability related to acute infection and febrile states; and general loss of functional capacity associated with aging [2,12].

Fall risk assessment and preventive interventions should start at initial admission to the hospital or long-term care facility. Within hospitals, bed alarms, sitters, and physical restraint orders have been used in the past to reduce the likelihood of patients falling [17]. However, restraints have been noted to pose an increased risk for severe injury (and aspiration) and are used only very rarely. Restraints must have 1:1 observation and a physician order [28]. While employing a bedside sitter seems a reasonable precaution, one study found that evidence is inconclusive whether the presence of a sitter decreases the number of falls [16].