Data analysis by ECRI on patient falls reveals common risk factors

Patient transfers accounted for nearly half of falls events reported to ECRI in a new analysis, underscoring how routine patient movement activities can create major safety vulnerabilities. 

WILLOW GROVE, Pa., May 26, 2026 /PRNewswire/ -- The latest data analysis from the ECRI and the Institute for Safe Medication Practices Patient Safety Organization (PSO) shows that patient transfers, toileting and ambulation-related falls are the most common event types. About 30 percent of falls reported involved patients under 65 years old, challenging the assumption that fall prevention is solely or exclusively an issue for older adults.

Falls Remain a Persistent Challenge

Falls remain one of the most persistent patient safety challenges in healthcare. An estimated 700,000 to 1 million hospitalized patients in the U.S. experience a fall each year. Falls can profoundly complicate a hospitalized patient's recovery, often leading to additional injuries, extended hospital stays, disrupted treatment plans, or even death. For some patients, a fall marks a turning point that means they must be discharged to a nursing facility or rehabilitation center rather than back home or to their previous care setting. The financial costs are significant as well, both for patients and the broader healthcare system.

Analysis of Patient Falls Data

ECRI and the ISMP PSO's dataset, one of the largest of its kind in the U.S., includes more than 8 million safety events submitted by healthcare providers nationwide, which ECRI analyzes to identify patterns in patient harm and evidence-based opportunities to improve care. ECRI examined 71,456 falls-related patient safety events reported in 2025. Building on the Agency for Healthcare Research and Quality Common Formats and ECRI's enhanced event taxonomy, the analysis used keyword and phrase searches within event descriptions to identify recurring event types and contributing circumstances.

Download Data Snapshot on Patient Falls

Data Findings

• When Falls Happen: Patient transfers, toileting, and ambulation—all routine, necessary care activities—collectively account for more than 85% of reported falls.
  • Transfer is by far the highest risk moment, accounting for nearly half of all falls (45.3%). Toileting is the second most common trigger at 30.7%, while falls occurring during ambulation accounted for 9.4%.
    
    
  • Transfer-related falls were defined as those that involve patient movement from one surface or location to another, such as between a bed, chair, stretcher, or wheelchair. Ambulation-related falls occurred while patients were walking or moving through care environments, with or without assistance, including in their hospital room or hallway.
• Which Patients are at Risk: Falls are not limited to older patients. Working-age adults (18–64) represented the largest single age group in this analysis, accounting for 29.3% of falls events. This is a reminder that fall risk assessment and prevention protocols, especially in acute care settings, should not overlook younger adults.
  
  
• Where Do Most Falls Occur: In this data snapshot, falls are overwhelmingly concentrated in acute care facilities (68.1%) such as hospitals. Falls were also reported across post-acute care facilities like nursing homes, rehabilitation centers, home health, ambulatory care behavioral health, and cancer centers. This is somewhat a reflection of the membership base of the ECRI and ISMP PSO, which includes more acute care hospitals and health systems than nursing homes and post-acute care facilities.
  
  
• Power of Reporting: The analysis demonstrates the importance of detailed event reporting.
  • More than 9,000 of the reports were noted as 'near-misses' or unsafe conditions (rather than serious events or incidents of harm), which reflects ongoing efforts to encourage reporting. Organizations that collect and analyze near miss events are given insight into conditions, workflows, and processes that could lead to harm and more importantly an opportunity to prevent harm.
    
    
  • Large "unknown" categories within fall location and patient age suggest an opportunity to better capture this information to strengthen organizations' ability to fully understand risk patterns and identify opportunities for improvement. 

Expert Perspective

Shannon Kooker
Vice President of Clinical Excellence and Patient Safety, ECRI 

"Falls are often viewed as isolated incidents, but the data consistently show that they are deeply connected to how care systems function," said Shannon Kooker, MSN, RN, CPPS, CPHQ, CIC, FAPIC, Vice President of Clinical Excellence and Patient Safety at ECRI. "Many falls occur during routine care activities that require coordination between caregivers, so we should be focusing on the systems surrounding patient movement and handoffs, not simply on individual patient or staff behavior."

Kristen Crandall
Associate Director, Total Systems Safety, ECRI

"Our work with health systems has shown that they can make meaningful progress when they seek to understand how fall prevention efforts are breaking  and then embrace systems thinking to redesign those efforts so that prevention is embedded into how everyday care is delivered," said Kristen Crandall, MSN, RN, CPN, Associate Director Total Systems Safety at ECRI. 

Polly Tremoulet
Director of Human Factors Engineering at ECRI

"Fall prevention requires more than alarms or checklists; it requires understanding how care is actually delivered and experienced in real clinical environments," said Polly Tremoulet, PhD, Director of Human Factors Engineering at ECRI. "When we apply human factors-based systems thinking after a fall or near-miss, we seek to understand how system design influences patient safety and identify ways to redesign care environments to better meet the needs of both staff and patients — from reconfiguring room layouts to ensuring practical tools like non-slip socks are consistently available."

Recommendations to Prevent Patient Falls 

To prevent patient falls, ECRI advises healthcare organizations to:

• Use fall event data proactively: In facility-specific datasets, identify operational vulnerabilities, workflow gaps, and recurring risks associated with patient movement and care transitions. For example, patient transfers and toileting protocols deserve the most immediate attention based on the nationwide ECRI and PSO data assessment.
  
  
• Design care delivery systems with human factors principles: Adding more staff reminders, hospital signage, or fall prevention technologies into broken systems isn't enough. Fall prevention "bundles" are a standard of care but falls persist. Adopt human-centered design and a systems safety perspective to move the focus from individual patient or worker compliance to system performance.
  
  
• Partner with patients' families and caregivers: Treat fall prevention as a holistic system, acknowledging that the family often possesses the most acute "baseline" knowledge of the patient. Integrate them into workflows to add a layer of defense that automated alarms and hourly checks simply cannot replicate.

Resources: ECRI Webinars on Fall Prevention

• Webinar | Enhancing Falls Prevention: Collaborative Informational Session
  
  
• Webinar | Preventing Falls with Injury: A Systems-Based Approach

ECRI is an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all healthcare settings. With a focus on technology evaluation and safety, ECRI is respected and trusted by healthcare leaders and agencies worldwide. Over the past six decades, ECRI has built its reputation on integrity and disciplined rigor, with an unwavering commitment to independence and strict conflict-of-interest rules. ECRI is the only organization worldwide to conduct independent medical device evaluations, with labs located in North America and Asia Pacific. ECRI is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Research and Quality. The ECRI and Institute for Safe Medication Practices PSO is a federally certified Patient Safety Organization (PSO) as designated by the U.S. Department of Health and Human Services. ECRI acquired The Institute for Safe Medication Practices (ISMP) in 2020 to address one of the most prolific causes of preventable harm in healthcare, medication errors; then acquired The Just Culture Company in 2024 to transform healthcare workplace cultures – thus creating one of the largest healthcare quality and safety entities in the world. Visit www.ecri.org.

SOURCE ECRI