Inpatient falls are a persistent patient safety concern1,2 and significant progress has been made in identifying prevention strategies to reduce their occurrence.1–11 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.12 Event reports submitted between July 1, 2023, and June 30, 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.

For full details and study findings, we recommend that facilities and providers review “The Overlooked Threat of Hospital Falls During the Discharge Period: A Statewide Retrospective Analysis of Patient Safety Event Reports” at doi.org/10.33940/001c.141403.

Disclosure

The authors declare that they have no relevant or material financial interests.

This article was previously distributed in a September 3, 2025, newsletter of the Patient Safety Authority, available at https://patientsafety.pa.gov/newsletter/Pages/newsletter-sept-2025.aspx.

About the Authors

Christine E. Sanchez (chrsanchez@pa.gov) is a research scientist on the Data Science & Research team at the Patient Safety Authority. She is responsible for utilizing patient safety data, combined with relevant literature, to develop strategies aimed at improving patient safety in Pennsylvania.

Rebecca Jones, director of Data Science & Research for the Patient Safety Authority, leads a multidisciplinary team advancing patient safety through research that informs improvements in healthcare systems and delivers insights that bridge the gap between evidence and real-world practice. A registered nurse with a Master of Business Administration in healthcare management and certifications in patient safety, human factors, and risk management, she brings clinical experience, analytical expertise, and systems thinking to complex challenges. She has authored more than 40 peer-reviewed publications and contributed to national patient safety efforts with organizations such as the Institute for Healthcare Improvement, the National Quality Forum, and the Society to Improve Diagnosis in Medicine.