WILLOW GROVE, PA — Patient transfers accounted for nearly half of more than 71,000 falls-related safety events reported last year, highlighting routine movement activities as a major source of risk for hospitals and healthcare providers, according to a new analysis by ECRI and the Institute for Safe Medication Practices Patient Safety Organization.
The findings come as healthcare systems continue to grapple with patient falls, a persistent safety challenge that affects an estimated 700,000 to 1 million hospitalized patients annually in the United States and can lead to injuries, longer hospital stays, higher treatment costs and, in some cases, death.
ECRI analyzed 71,456 falls-related patient safety events reported during 2025 from a database containing more than 8 million safety events submitted by healthcare organizations nationwide.
The review found that patient transfers — such as moving between beds, chairs, wheelchairs and stretchers — accounted for 45.3% of reported falls, making them the single most common circumstance associated with falls.
Toileting-related incidents represented 30.7% of reported falls, while falls occurring during patient ambulation accounted for 9.4%.
Collectively, those three routine care activities were associated with more than 85% of all falls identified in the analysis.
The report also challenges assumptions that fall prevention is primarily an issue for older adults.
Adults between the ages of 18 and 64 accounted for 29.3% of reported falls, the largest single age group identified in the analysis. ECRI said the findings suggest healthcare organizations should ensure fall-prevention efforts extend beyond elderly patient populations.
Most reported falls occurred in acute-care settings such as hospitals, which accounted for 68.1% of events. Falls were also reported in nursing homes, rehabilitation facilities, home health settings, ambulatory care centers, behavioral health facilities and cancer treatment centers.
Shannon Kooker, ECRI’s vice president of clinical excellence and patient safety, said the data indicate that fall prevention efforts should focus on healthcare delivery systems rather than isolated incidents.
“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,” Kooker said.
The analysis also found more than 9,000 reported events were categorized as near misses or unsafe conditions rather than incidents resulting in harm. ECRI said such reports can help organizations identify risks before injuries occur.
Researchers noted that large numbers of reports lacked information about patient age or the specific location of a fall, limiting the ability to identify patterns and target prevention efforts.
Kristen Crandall, ECRI’s associate director of total systems safety, said organizations that examine why prevention efforts fail can make measurable progress by redesigning workflows and embedding safety measures into routine care processes.
To reduce falls, ECRI recommends that healthcare organizations use fall-event data to identify operational weaknesses, apply human-factors principles when designing care systems and involve family members and caregivers more directly in prevention efforts.
The organization said patient transfers and toileting procedures warrant immediate attention based on the national findings, given their outsized role in reported falls.
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