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 Journal List
 Int J Health Policy Manag
 v.8(5); 2019 May
 PMC6571495

Int J Health Policy Manag. 2019 May; 8(5): 300–306.

Published online 2019 Mar 9. doi: 10.15171/ijhpm.2019.11
PMCID: PMC6571495
PMID: 31204446

Risk Factors for Falls in Hospital In-Patients:

A Prospective Nested Case Control Study
Zhila Najafpour, 1 ,* Zahra Godarzi, 2 Mohammad Arab, 3 and Mehdi Yaseri 4
Author information Article notes Copyright and License information Disclaimer
This article has been cited by other articles in PMC.

Associated Data
Supplementary Materials
Go to:

Abstract
Background: Patient falls are considered a challenge to the patient’s safety in hospitals, which,
in addition to increasing the length of stay and costs, may also result in severe injuries or even
the death of the patient. This study aims to investigate the associations between risk factors
among fallers in comparison with the control group.

Methods: A prospective nested case control study was performed on 185 patients who fell and
1141 controls were matched with the patients at risk of fall in the same ward and during the same
time. This study was conducted in a university educational hospital in Tehran with 800 beds
during a 9-month period. The data included demographics, comorbidities, admission details,
types of medication, clinical conditions, and activities before or during the fall. The data was
collected from clinical records, hospital information system, error reporting system and
observations, and the interviews with the fallers, their families and care givers (physicians,
nurses, etc). Data analysis was conducted through time-based matching using a multi-level
analysis.

Results: In a multilevel model including patient-related, medication, and care-related variables,

the factors that were significantly associated with an increased risk of patient falls included:
longer length of stay (odds ratio [OR] = 1.01; CI=0.32 to 0.73), using chemotherapy drugs,
sedatives, anticonvulsants, benzodiazepines, and angiotensin-converting enzyme (ACE)
inhibitors, visual acuity (OR=6.93; CI=4.22 to 11.38), balance condition (OR= 6.41; CI=4.51 to
9.11), manual transfer aid (OR=8.47; CI=5.65 to 12.69), urinary incontinence (OR= 8.47, CI=
5.65 to 12.69), and cancer (OR=2.86, CI=1.84-4.44). These factors were found to be associating
with more odds for a falling accident among patients. Several characteristics such as fall history
(OR=0.48; CI= 1.003 to 1.02), poly-pharmacy (OR=1.37, CI=00.85 to 2.2), stroke (OR=0.94,
CI= 0.44 to 2.02), and nurse to patient ratio (incidence rate ratio=1.01, CI=0.01 to 0.03) were not
significantly associated with falling in hospitals.
Conclusion: It seems that a combination of both patient-related factors and history of medication
should be considered. Moreover, modifiable clinical characteristics of patients such as vision
improvement, provision of manual transfer aid, diabetes control, regular toilet program, and drug
modification should be considered during the formulation of interventions.

Keywords: Accidental Fall, Hospital, Risk Factors, Nested Case Control

Go to:

Background
Patient falls within hospitals continue to be a serious concern and are the most common adverse
events leading to injury, longer lengths of stay, and increased costs among hospitalized
patients.1,2

The rate of falls varies considerably by hospital and by unit type 3,4 However, there is an
agreement that falls are a common problem in hospitals: fall rates range from 2.6 to 7 per 1000
patient days, and almost 23% to 42% of the falls contribute to at least one type of injury and 2%
to 9% of them lead to serious injuries.5-7 The consequences of fall-related injuries are also
associated with substantially raised costs (fallers with serious injuries are charged $13 316 more
than non-faller inpatients and, on average, have a 6-8 day longer stay at hospitals).8,9 In addition
to physical injuries, patients are disposed to mental harms such as anxiety, fear of falling, and
loss of self-confidence.10

The first step in preventing falls is the identification of high-risk patients. In this regard, risk
factors are considered as the key to identifying patients susceptible to falling and selecting
effective measures in fall prevention. A plethora of research in the literature has identified a
number of risk factors as influential in patients’ falls.11

Different studies have marked various explications of risk factors,11 and there is no definitive
consensus on the type and number of risk factors leading to a fall. It is imperative that
comprehensive information be gathered about the risk factors of falling among hospitalized
patients for the purpose of designing preventive interventions. This is mainly due to the fact that
despite the implementation of various trials worldwide, no fully effective proceeding has yet
been developed to targeted fall preventive interventions.12

Risk factors are classified into two types of (a) intrinsic factors including age, gender,
musculoskeletal disorders, patient’s imbalance and using drugs; and (b) extrinsic factors
including the weakness of the health system in the maintenance and design of medical
equipment, human resources, communication, training, and team work. The negative interactions
between intrinsic and extrinsic risk factors lead to serious physical injuries.13

Due to the risk of significant injury, increased costs, and emotional harms, reducing the number
of falls in hospitals is a major priority. Despite concerted efforts to prevent patient falls in
hospitals, still there are identifiable gaps in the literature and hospitals continue to struggle with
the consequences of patient falls. Fall prevention programs are most efficient when linked to the
modifiable risk factors. Therefore, it is imperative to develop some methods to accurately
identify those at the highest risk in order to formulate targeted interventions. Further research is
required to confirm the risk factors. Along this line, we conducted a nested case-control study to
determine patient-related, medication, and care-related predictors of inpatient falls and to
investigate the associations between risk factors and falling incidents in a general hospital.

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Methods
The present study is a prospective nested case-control investigation conducted on patients
admitted in a general hospital with an annual admission of 24 000 patients during a period of 9
months (June 2016–March 2017). The units were general, heart surgery, neurosurgery,
orthopedics, general surgery, hematology, emergency, and gynecology. A total of 1326 patients
were enrolled in the study. Of these, 185 cases and 1141 controls were recruited into the study.

Case and Control Groups

In our study, the cases were patients admitted during the study period who had a falling incident
at the hospital. In this study, a patient fall is defined “as an unplanned descent to the floor with or
without injury to the patient.”14 A total of 185 falls were recorded during the study period in
different wards. Meanwhile, we analyzed only the first falls, excluding the second falls to reduce
the bias.15

For a comparison group, all patients admitted to the participating wards were assessed by nurses
(at least within 24 hours of admission) using a Morse Fall Scale and the patients were considered
as high-risk and eligible for inclusion if they had scores higher than 45. A total of 1141 patients
were enrolled in the study as the control group (high-risk patient). All cases were matched with
high-risk patients hospitalized in the same ward and at the same time.

Data Collection

A data collection tool developed by the research team was employed for recording variables
from fallers and controls. These variables are presented in Table 1. The data were collected by
the researchers from patient records, hospital information system, error reporting system,
environmental observations, and interviews with the cases and their families, physicians, and
nurses (a median of 1 day after occurring a fall to facilitate collecting information before the
patients were discharged) (See Supplementary file 1).

Table 1

Variables on Fall Data Collection Tool

Variables Collected for Both Fallers and Controls
Patient demographics
Medications taken within 24 hours
Fall risk level (assigned via Morse Falls Scale by the nurse at admission)
History of fall
Health status variablesa
Additional Variables Collected Only for Patients Who Fell
Place, date, and time of fall
Activity level at time of fall
Location of fall
Type and severity of injuryb
a
 History or presence of depressive disorder, visual impairment, motor disorders, manual transfer
aid, history of stroke, Parkinson’s disease, diabetes, urinary incontinence, and cancer.
b
Type and severity of injury such as minor injury (patients’ complaints of pain, the need for ice
packs, bandages, cleaning wounds, swelling, analgesics, etc), moderate injury (cramps,
stretching of the muscles, requiring stitches or bed rest), severe injury or death (fracture, surgery,
etc).16

The post-fall conditions of the patient were recorded by the physician. After any patient fell,
physicians examined the details of the injuries and prescribed treatment at a maximum interval of
1 to 2 days.

A wealth of studies has called for the need for employing multiple methods for collecting valid
data on patients’ falls.17,18 Therefore, in this study, in addition to hospital error reporting systems,
all the patients admitted during the study period were interviewed before being discharged from
the hospital on their falling experiences. Their records were also reviewed on a daily basis with
the aim of detecting the error reporting gaps.

Identification of high-risk patients was conducted by the Morse Fall Scale in all the wards. The
Morse Fall Scale is a fall risk assessment tool that has been developed using a rigorous research
design19 and is valid for identifying the patients at high risk of falling.20 It consists of 6 items:
history of falling (3 months ago) (possible score: 0 or 25), presence of secondary diagnosis (0 or
15), use of an ambulation aid (0, 15, or 30), IV or IV access (0 or 20), type of gait (0, 10, 20) and
mental status (0 or 15). The total score can range from 0-12520 and we considered only patients
with scores of more than 45 as high-risk patients.

Medication

The patients’ medications were identified on admission and discharge. The details of
medications received by both cases and controls were obtained through the hospital information
system, patient records, and interviewing the patients or their families about their medication
history during the last two weeks. All drugs used were evaluated and categorized by a clinical
pharmacologist. Medications were classified into 21 groups: sedatives, antiarrhythmic agents,
anti-diabetic agents, anticoagulants, vasodilators, anticonvulsants, benzodiazepines, angiotensin-
converting enzyme (ACE) inhibitors, beta blockers, narcotic analgesics, antipsychotics, calcium
channel blockers, alpha blockers, chemotherapy, non-steroidal, hypertensive agents, anti-
infective agents, antihistamine drugs, autonomic drugs, gastrointestinal drugs, and respiratory
tract agents.

Data Analysis

Data were entered into Microsoft Excel, cleaned, and then transferred to STATA version 11.0
(StataCorp Lp). The values were expressed as means, standard deviations, ranges, and precents.
Independent variables were age, gender, Morse scale score, history of falls, type and number of
medications, length of stay, and comorbidities. The dependent variable was the rate of fall. To
consider the matching in our study, we used a multilevel analysis (patient and ward levels). The
precision of the estimates was presented by 95% CI and a P value less than .05 was considered
statistically significant. Chi-square and Fisher exact tests were used to compare characteristics of
the patients (case and control groups) for categorical variables. To compare continuous variables,
analysis of variance and the Kruskal-Wallis test were used as appropriate tests. The magnitude of
the relationship between risk factors and falling was quantified using the odds ratio (OR).
Logistic regression was used to calculate both the crude OR and the adjusted OR. We adjusted
the model for age, Morse scale score, history of prior falls and length of stay. Also, a Poisson
regression was used to assess the effect of ward variable and patient fall (such as the ratio of
nurses to patients).

Go to:

Results
Characteristics of Cases and Controls

In this study, 185 patients were in the case group and 1141 patients comprised the control group.
The mean ages of the patients in case and control groups were 52.9 and 58.6, respectively. About
57% of the patients in the case group and 45% of the patients in the control group were females.
The correlation results among the studied variables revealed no statistically significant difference
in terms of gender and age. However, there was a significant difference between the risk factors
such as prior fall history (3 months ago) and length of stay (P ≤ .05). However, only odds of
falling with longer length of stay were increased (Table 2).

Table 2

Characteristics of Cases and Controls

Control a (n = OR (Crude) a P
Variables Case a (n = 185)
1141) (95% CI) Value
58.6, 17.2 (57.6- 52.9, 18.5 (50.2-
Age (y), mean, SD (range) 0.99 (0.98 to 1.00) .069
59.6) 55.6)
Gender
Male, No. (%) 630.0 (55%) 106.0 (57) 0.98 (0.72 to 1.34) .901
Female, No. (%) 511.0 (45%) 79.0 (43)
Mean 'Morse Falls Scale Score', 60.4, 15.8 (59.4- 47.4, 19.0 (44.6- 0.93 (0.93 to 0.95) <.001
mean, SD (range) 61.3) 50.1)
Fall history (3 mounts ago), No.
171.0 (14%) 42.0 (22.7%) 0.48 (0.32 to 0.73) <.001
(%)
Mean length of stay, days, mean, 10.2, 12.8 (7.2- 13.84, 14.3
1.01 (1.00 to 1.02) <.001
SD (range) 8. 4) (11.8-15.9)

Abbreviations: OR, odds ratio; SD, standard deviation.

a
The estimates accompanied with 95% CI in the parenthesis based on multilevel logistic
regression.

Medication

Table 3 shows the OR for taking drugs and falling. Findings of our study confirmed that using
sedative, anticonvulsants, anti-diabetic agents, benzodiazepines, ACE inhibitors, anti-infective
agents, antihistamine, and chemotherapy drugs were significantly different between the case and
the control groups. The use of the mentioned drugs was associated with higher odds for a falling
accident among the patients. However, there were not any strong associations between the crude
and the adjusted data for poly-pharmacy (use of ≤ 5 medicines) and patient fall. Poly-pharmacy
was used in 159 cases (85.9%) and 918 controls (80.6%) (Table 3).

Table 3

Medications Administered to Cases and Controls

Case Control
Pharmaceutical Use OR (Crude) (95% CI) P Value
No. (%) No. (%)
Sedative/hypnotics 131 (70.8) 709 (62.2) 1.47 (1.04 to 2.06) .02
Antiarrhythmic agents 62 (33.5) 384 (33.7) 0.99 (0.71 to 1.37) .95
Anti-diabetic agents 19 (10.3) 32 (2.8) 0.16 (0.13 to 0.18) <.001
Anticoagulants 128 (69.2) 815 (71.6) 0.89 (0.63 to 1.25) .51
Vasodilators/vasoactive 37 (20.0) 275 (24.1) 0.78 (0.53 to 1.15) .219
Anticonvulsants, miscellaneous 108 (58.4) 576 (50.6) 1.37 (1.00 to 1.87) .04
Antidepressants 18 (9.7) 69 (6.1) 1.67 (0.97 to 2.87) .06
Benzodiazepines 96 (51.9) 498 (43.7) 1.38 (1.01 to 1.89) .03
ACE inhibitors 96 (51.9) 714 (62.7) 0.64 (0.46 to 0.87) .005
Beta blockers 91 (49.2) 602 (52.9) 0.86 (0.63 to 1.17) .35
Narcotic analgesics 143 (77.3) 874 (74.7) 1.03 (0.71 to 1.49) .86
Antipsychotics 49 (26.5) 345 (30.2) 1.36 (0.84 to 2.21) .19
Calcium channel blockers 89 (48.1) 606 (53.2) 0.18 (0.59 to 1.11) .19
Alpha blockers 90 (48.6) 38 (2.9) 0.82 (0.60 to 1.12) .22
Chemotherapy 23 (12.0) 67 (5.9) 2.27 (1.37 to 3.75) .001
Non-steroidal/anti-inflammatory 140 (75.7) 874 (76.7) 1.07 (1.06 to 5.8) .70
Hypertensive agents 50 (27.0) 368 (32.3) 0.77 (0.54 to 1.09) .15
Anti-infective agents 148 (80.0) 789 (69.3) 1.70 (1.21 to 2.59) .003
Antihistamine drugs 23 (12.4) 78 (6.8) 1.93 (1.17 to 3.16) .009
Autonomic drugs 53 (28.6) 331 (29.1) 0.98 (0.69 to 1.38) .90
Gastrointestinal drugs 152 (82.2) 910 (79.9) 1.15 (0.77 to 1.73) .40
Respiratory tract agents 38 (20.5) 238 (20.9) 0.97 (0.66 to 1.43) .90
Ploy-pharmacy 159 (85.0) 918 (80.0) 1.47 (0.94 to 2.28) .08
Ploy-pharmacy (adjusted)a 159 (85.0) 918 (80.0) 1.37 (0.85 to 2.20) .18
Open in a separate window

Abbreviations: OR, odds ratio; ACE, angiotensin-converting enzyme.

Based on multilevel logistic regression.

a
Adjusted with variables of age, gender, Morse scale score, history of prior fall, and length of
stay.

Clinical Conditions of Patients

In terms of the clinical conditions of patients under study, the cases were reported to have
significantly higher rates of depression, visual impairment, balance disorder, manual transfer aid,
urinary incontinence, cancer, Parkinson’s disease, and diabetes mellitus. The results showed that
patients with this comorbidity had higher odds for falling accidents than others (Table 4).

Table 4

Patient Care-Related Factors

Case Control 95% CI
Variable Adjusted OR a P>|z|
No. (%) No. (%) Lower Upper
Depression 27 (14.6) 32 (2.8) 5.90 <0.001 3.44 10.12
Vision problem 38 (20.5) 42 (3.7) 6.93 <0.001 4.22 11.38
Gait disorder 87 (47.0) 140 (12.3) 6.41 <0.001 4.51 9.11
Use of walking aids 71 (40.5) 91 (8.1) 8.47 <0.001 5.65 12.69
Stroke 8 (4.3) 52 (14.6) 0.94 0.884 0.44 2.02
Incontinence 28 (15.1) 40 (3.5) 4.86 <0.001 2.91 8.10
Parkinson disease 3 (1.6) 3 (0.3) 4.96 <0.001 0.70 6.84
Cancer 33 (17.8) 80 (7.0) 2.86 <0.001 1.84 4.44
Diabetic 19 (10.3) 32 (2.8) 2.88 <0.001 1.54 5.38

Abbreviation: OR, odds ratio.

a
Based on multilevel logistic regression and adjusted with variables of age, gender, Morse scale
score, history of prior fall, and length of stay.

Fall Reports
Among fall incidents, 63% of the fallers experienced varying degrees of injuries from minor to
major (minor: 46%, moderate: 12%, and sever injury or death: 4%). Some 67% of the fallers
were unassisted and had no observer or a manual transfer aid. Meanwhile, activity restriction
(complete bed rest) had been prescribed by physicians in 24% of fallers before the fall occurred.
The most frequent place before or at the time of fall was the bathroom (39%), and the majority of
falls (41%) occurred during the night shift. Although the nurse-to-patient ratio was lower in night
shifts (incidence rate ratio  = 1.01, CI = 0.01 to 0.03, P > .05), it was not significantly associated
with increased risk of falls. From the total falls, 51% of the actual fall incidents were reported by
nurses and the reporting error system. Others were disclosed through interviews before patients’
discharge (Table 5).

Table 5

Activities of Patients Prior to or During Falls

Activity No. Percent
Getting up from bed, wheelchair, chair 48 26
Walking 62 34
Being transported 2 1
Bathroom (toileting, shower) 73 39
Sum 185 100
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Discussion
Hospital falls have a multiple etiology. The results of this study showed that patient-related
factors such as longer length of stay, and clinical risk factors such as visual impairment, balance
difficulties, manual transfer aid, and urinary incontinence as well as medication with drugs such
as sedatives, anticonvulsants, anti-diabetic agents, benzodiazepines, ACE inhibitors, anti-
infective agents, antihistamine, and chemotherapy drugs increased the risk of patient falls.

Patient-Related Factors

The findings of this study indicated that the demographic variables (ie, age and gender) were not
risk factors in our study. In 2009, the American Centre for Disease Control reported that the
incidence of fall and fall-related injuries for males and the elderly above 85 years of age was four
times greater than the patients aged 65-74.21,22 In the DUNLOP study, conditions associated with
age such as arthritis, diabetes, heart disease, urinary incontinence, and visual impairment were
suggested as predictors of the increased risk of falling among patients.23 In the study of Quigley
et al,24 there has been a positive correlation between age increase and fall-induced injuries among
hospitalized patients. However, in some studies, similar to ours, there was no correlation
between age or gender and patient falls.5,25-27 Therefore, various studies have revealed
inconsistent findings. However, aging, in combination with factors such as poor mobility or
confusion, may result in a fall and the subsequent injuries.
The findings have indicated that the risk of repeated falls in patients with fall history is higher.
Our results did not, however, confirm any association with the increased risk of patient falls. The
results of other studies confirm that circumstances or characteristics of prior falls were repeated
in subsequent falls.27,28 In addition, the history of falls may mask the influence of factors causing
these earlier falls in a way that it can be considered as an indicator of an underlying problem like
impaired balance.29 Deandrea reported this factor as helpful in identifying individuals at high risk
of falling and recommended the inclusion of such factors in the fall risk assessment tools
administered during the hospital admission.27 In our study, neglecting the prior fall history
among cases during the initial assessment due to difficulties such as confusion, mental health
problems, and the lack of cooperation between the patient and the nurses in addition to the
nurses’ failure to ask about the history of falls led to the loss of this piece of information. In this
regard, the role of nurses in effective communication with patients is paramount. It is suggested
that in patients with one or more experiences of fall, the conditions of the previous falls and their
underlying causes should be thoroughly investigated. In the same line, Healey et al has
recommended locating the beds of such patients as close to the nursing station as possible.30

Balance difficulties and use of walking aids are important risk factors that have increased the rate
of falls. In the studies by Quigley et al31 and Mayo et al,28 the decreased mobility and use of an
assistive device were associated with injurious falls. However, the study of Baloh et al suggested
that there was no clear causal relationship between the poorer balance and fall incidents.32 In
addition to increasing the access to walkers and canes at the bedside, families should be
encouraged to bring the patient’s walkers or assistive devices from home to be used in the
hospital.33 Moreover, physical therapy can significantly improve the motor performance which is
known as a risk factor for falling.34

Another risk factor associated with falls was the cancer disease already confirmed in the study of
Capone et al35 and Spolesra et al,36 similar to the present study. Hitcho et al reported that patients
under oncology treatment may be more prone to fall-related injuries due to anemia,
thrombocytopenia, and risk for pathologic fracture.33 However, the risk factors among patients
with cancer are different from other patients so that the most common reported factors such as
pain, type of cancer, metastasis, antipsychotics, antidepressants, and blood transfusions are
influential in a fall incident.35 It seems that there is a need to develop a specific assessment tool
or to use complementary tools to predict more precisely the risk of fall among patients receiving
oncology treatment.

Other relevant factors addressed in this study were visual impairments as well as incontinence
and frequent urination. Patients with visual deficits are more likely to fall due to their reduced
visual acuity, poor balance, false perception of environmental elements, and sensory loss.37,38
Leat et al suggested implementing an assessment of vision at hospital admissions would be
useful for identifying patients who are at risk for falls due to poor vision,39 but it seems that these
preventive interventions (vision assessment and eyeglass prescription) may be unrealistic for a
hospital setting, hence we emphasize that the patients with a visual impairment use glasses while
they are in the hospital, encourage regular eye examinations especially for the elderly, and keep
adequate light levels at night in hospitals.
The effect of incontinence and frequent urination is confirmed in the study of Krauss et al.40
Also, Oliver et al suggest the provision of safe footwear and attention to the causes of
incontinence urination. They illustrate that acutely ill patients are most mobile when walking
between their bedsides to the toilet.41 In addition, creating a regular toilet program for fall-
susceptible patients and the availability to assistive devices may decrease the risk of fall among
such patients.42 In sum, the prevention of falls in hospitals may require innovative approaches.

Patient Medication

The findings of the present study also indicated that medication with sedatives, anticonvulsants,
benzodiazepines, ACE inhibitors, anti-infective agents, antihistamine drugs, and chemotherapy
drugs increases the rate of falling. A number of studies have marked significant associations
among medication, fall incidents, and fall-induced injuries.43-45

In this study, antiarrhythmic, vasoactive and ACE inhibitor drugs were classified as a
subcategory of cardiac drugs and hypertensive agents, with a greater rate of falling among
consumers of ACE inhibitor drugs. In addition, there was no association between the use of
antihypertensive agents, which lead to orthostatic hypotension, and the patient falls.46 However,
intake of hypotonic and diabetic drugs increased the rate of fall incidents among patients. In his
study, Schwartz et al47 drew up a link between the intake of thiazolidinediones with fall-induced
fractures. Also, diabetic patients may have a higher incidence of fall due to hypoglycemia.
However, some studies have suggested no impact of diabetes and hypotonic medications on
enhancing the risk of falling.48-50 In the present study, hypertensive drugs such as diuretics had no
effect on patient falls. Shuto et al stated that medical professionals should monitor patients for
the initial three days after starting treatment with any of these medications. It is recommended
that we modify the use of drugs with a potential fall-increasing nature in terms of dose and time
of use. It is also advisable to use drugs under the supervision of a physician.51

Consistent with the studies of Mion et al52 and Kojima et al,53 the role of poly-pharmacy or high
dose drug intake on increasing the risk of falls was not confirmed and it seems that intervention
studies are required to clarify the causal relationship between poly-pharmacy and fall incidence.

Fall Circumstances

The results of the present study indicated that the primary activities before or during fall included
walking and using the bathroom. Also, some studies suggested evidence of fall incidents for
patients who have repeatedly used the bathroom or toilet, which was confirmed by the study of
Chelly et al.6 The findings have indicated that most falls have occurred when the patient has been
alone. Thence, some interventions, including scheduled toileting, regular round of nurses and
admission of fall-prone patients in places directly visible from the nursing station or adjacent to
the nursing station can be effective.

In terms of fall-induced injuries, more than 63% of fall incidents were associated with minor to
severe injuries. Hitcho et al33 reported that up to 42% of the falls resulted in injury. Therefore, it
is highly advisable to use post-fall analysis tools, environment monitoring and assessment, and
interviews with the involved individuals, especially the fallers, to facilitate the development of
specific preventive measures in hospitals.

This study had a few limitations: first, it was conducted in a general hospital which may affect its
generalization. This problem was somewhat moderated by selecting a large size study population
from different specialty wards. The second limitation was that there was a problem of self-
reported recall of falls by older patients due to difficulties in speaking in Persian or those who
were all alone, which led to underreporting. Finally, considering the limited number of samples
in the control group, we could not match the patients for age, gender, etc, which could also lead
to biased results.

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Conclusion
In this study, patient-related factors were found to increase the risk of fall. Fall prevention
strategies should be linked to the patient characteristics that cause a patient to fall. Therefore,
based on our results, strategies should focus on modifiable and effective risk factors such as
patients with longer length of stay, history of falls, Morse Falls Scale score, visual acuity,
balance, manual transfer aid, urinary incontinence, cancer and diabetes, and taking medications
such as chemotherapy, sedatives, anticonvulsants, Benzodiazepines, ACE inhibitors, anti-
infective agents, and antihistamine. A focus on post-fall interventions enjoying a patient-oriented
approach is required to modify the risk factors associated with fall incidents. The condition and
setting where the fall has occurred should be well identified and corrected or at least mitigated. It
is suggested that similar studies be conducted focusing on environmental and organizational
factors as well as their causality relationships in different types of hospitals.

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Acknowledgements
We thank the patients for their participation and the staff at hospital for their help. Also we
would like to thank from Dr. Marzieh Nosrati from faculty of Pharmacy affiliated to Tehran
University of Medical Sciences, Tehran, Iran for valuable guidance.

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Ethical issues
This study was conducted with the approval of ethics committee affiliated of Tehran University
of Medical Sciences (TUMS), Tehran, Iran.

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Competing interests
Authors declare that they have no competing interests.

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Authors’ contributions
ZN: writing the original article. ZN, ZG: Gathering the data and cooperating in analysing it. MA:
project consulter and editing the article. MY: Analysing data. All authors read and approved the
final manuscript.

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Authors’ affiliations
1
Department of Health Care Management, School of Public Health, Ahvaz Jundishapur
University of Medical Sciences, Ahvaz, Iran. 2Department of Pharmacoeconomics and
Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences,
Tehran, Iran. 3School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
4
Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of
Medical Sciences, Tehran, Iran.

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Supplementary files
Supplementary file 1 contains interviewing protocol.

Click here for additional data file.(46K, pdf)

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Key messages
Implications for policy makers

 We identify contributory factors affecting fall incidents with the aim of meeting hospital
managers’ needs for timely and relevant intervention to improve patient safety in
healthcare systems.
 These findings are applicable in all hospitals.

Implications for public

The results of the present study reveal factors affecting fall incidents, can be helpful in
identifying high risk patients, can encourage the advocacy and the involvement of patients in
devising strategies to eliminate such barriers, and can finally help prevent the occurrence of falls,
especially in elderly patients.

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Notes
Citation: Najafpour Z, Godarzi Z, Arab M, Yaseri M. Risk factors for falls in hospital in-
patients: a prospective nested case control study. Int J Health Policy Manag. 2019;8(5):300–306.
doi:10.15171/ijhpm.2019.11

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  Review Fall and injury prevention.[Annu Rev Nurs Res. 2006]
 Characteristics and circumstances of falls in a hospital setting: a prospective analysis.[J
Gen Intern Med. 2004]
 Falls in English and Welsh hospitals: a national observational study based on
retrospective analysis of 12 months of patient safety incident reports.[Qual Saf Health
Care. 2008]

See more ...

 Falls among older adults--risk factors and prevention strategies.[J Safety Res. 2005]

 Falls among older adults--risk factors and prevention strategies.[J Safety Res. 2005]
 Review Falls in older people: epidemiology, risk factors and strategies for prevention.
[Age Ageing. 2006]

 Consequences of falling in older men and women and risk factors for health service use
and functional decline.[Age Ageing. 2004]

 Review Inpatient fall prevention programs as a patient safety strategy: a systematic

review.[Ann Intern Med. 2013]
 Predicting which patient will fall again ... and again.[J Adv Nurs. 1993]

 Falls and consequent injuries in hospitalized patients: effects of an interdisciplinary falls

prevention program.[BMC Health Serv Res. 2006]

 Effects of an intervention to increase bed alarm use to prevent falls in hospitalized

patients: a cluster randomized trial.[Ann Intern Med. 2012]
 Does access to bed-chair pressure sensors reduce physical restraint use in the
rehabilitative care setting?[J Clin Nurs. 2006]

 A prospective study to identify the fall-prone patient.[Soc Sci Med. 1989]

 Validity of the Morse Fall Scale implemented in an electronic medical record system.[J
Clin Nurs. 2014]

 Falls risk among a very old home-dwelling population.[Scand J Prim Health Care. 2009]
 Predictors of serious fall injury in hospitalized patients.[Clin Nurs Res. 2015]
 Incidence of functional limitation in older adults: the impact of gender, race, and chronic
conditions.[Arch Phys Med Rehabil. 2002]
 Reducing serious injury from falls in two veterans' hospital medical-surgical units.[J Nurs
Care Qual. 2009]
 Characteristics and circumstances of falls in a hospital setting: a prospective analysis.[J
Gen Intern Med. 2004]

See more ...

  Review Risk factors for falls in older people in nursing homes and hospitals. A
systematic review and meta-analysis.[Arch Gerontol Geriatr. 2013]
 Risk factors for fractures due to falls.[Arch Phys Med Rehabil. 1993]
 Validity of the interRAI Acute Care based on test content: a multi-center study.[Aging
Clin Exp Res. 2011]
 Using targeted risk factor reduction to prevent falls in older in-patients: a randomised
controlled trial.[Age Ageing. 2004]

 Reducing serious injury from falls in two veterans' hospital medical-surgical units.[J Nurs
Care Qual. 2009]
 Risk factors for fractures due to falls.[Arch Phys Med Rehabil. 1993]
 Age-related changes in vestibular function: a longitudinal study.[Ann N Y Acad Sci.
2001]

See more ...

 Predictors of a fall event in hospitalized patients with cancer.[Oncol Nurs Forum. 2012]
 Do older adults with cancer fall more often? A comparative analysis of falls in those with
and without cancer.[Oncol Nurs Forum. 2013]
 Characteristics and circumstances of falls in a hospital setting: a prospective analysis.[J
Gen Intern Med. 2004]

 Associations of visual function with physical outcomes and limitations 5 years later in an
older population: the Beaver Dam eye study.[Ophthalmology. 2003]
 Central and peripheral visual impairment and the risk of falls and falls with injury.
[Ophthalmology. 2010]
 Prevalence of vision loss among hospital in-patients; a risk factor for falls?[Ophthalmic
Physiol Opt. 2018]

 A case-control study of patient, medication, and care-related risk factors for inpatient
falls.[J Gen Intern Med. 2005]
 Preventing falls and fall-related injuries in hospitals.[Clin Geriatr Med. 2010]
 Cluster randomised trial of a targeted multifactorial intervention to prevent falls among
older people in hospital.[BMJ. 2008]

 An evaluation of risk factors for in-patient falls in acute and rehabilitation elderly care
wards.[Gerontology. 1996]
 Relationship between the administration of selected medications and falls in hospitalized
elderly patients.[Ann Pharmacother. 1995]

 Orthostatic hypotension and risk of cardiovascular disease in elderly people: the

Rotterdam study.[J Am Geriatr Soc. 2008]
 Older women with diabetes have a higher risk of falls: a prospective study.[Diabetes
Care. 2002]
  Review Diabetes medications related to an increased risk of falls and fall-related
morbidity in the elderly.[Ann Pharmacother. 2010]
 Review Meta-analysis of the impact of 9 medication classes on falls in elderly persons.
[Arch Intern Med. 2009]
 Medication use as a risk factor for inpatient falls in an acute care hospital: a case-
crossover study.[Br J Clin Pharmacol. 2010]

 Falls in the rehabilitation setting: incidence and characteristics.[Rehabil Nurs. 1989]

See more ...

 Characteristics and circumstances of falls in a hospital setting: a prospective analysis.[J

Gen Intern Med. 2004]

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