Patient safety is currently one of the main pillars of care quality in health services, especially in the hospital setting, where adverse events can result in significant clinical, functional, and economic impacts. Among these events, hospital falls stand out due to their high frequency and potential to cause physical harm, prolong hospital stays, and increase morbidity and mortality, particularly among elderly and clinically vulnerable patients (REIS; MARTINS; LAGUARDIA, 2013; GOUVÊA; TRAVASSOS, 2010). In this context, fall prevention has become an integral part of international patient safety protocols and institutional hospital quality programs.

Falls in the hospital setting are considered multifactorial events, associated with intrinsic and extrinsic factors related to the patient, the healthcare team, and the institutional structure. Evans et al. (2001) identified factors such as advanced age, cognitive impairment, functional limitations, and medication use as important determinants of fall risk in hospitalized patients. More recently, Morris et al. (2022) emphasized that the combination of clinical frailty, reduced mobility, and polypharmacy significantly increases the incidence of in-hospital falls, particularly in medium- and high-complexity units.

The elderly population represents one of the groups most susceptible to hospital falls, especially due to the presence of chronic diseases, sarcopenia, balance impairments, and functional dependence. Freire et al. (2024) demonstrated that older adults with diabetes mellitus have an increased risk of falls due to neuropathies, visual impairments, and functional impairment. Similarly, Nakashima et al. (2025) demonstrated a significant association between laboratory-based frailty and the occurrence of in-hospital falls in older adults, reinforcing the importance of comprehensive geriatric assessment during hospitalization.

In addition to clinical conditions, several studies highlight that medications potentially associated with sedation, hypotension, and neurological changes may directly contribute to an increased risk of falls in the hospital setting. Cox et al. (2023) observed a high prevalence of medications linked to an increased risk of falls in hospitalized older adults, while Barker et al. (2022) discussed the association between the continuous use of low-dose aspirin and a higher incidence of falls and fractures in healthy older adults. These findings highlight the importance of medication reviews as a preventive measure in hospitals.

The implementation of institutional fall prevention protocols has demonstrated a positive impact on reducing adverse events related to patient safety. Ximenes et al. (2021) demonstrated that educational interventions targeting multidisciplinary teams significantly contribute to improved adherence to preventive measures. Concurrently, De Figueiredo et al. (2026) emphasized that adequate adherence to fall prevention protocols promotes greater patient safety and a reduction in hospitalization-related complications.

Another relevant aspect concerns patients’ own perceptions of fall risk and their active participation in preventive strategies. Dabkowski et al. (2022) observed that many hospitalized patients have difficulty recognizing their actual level of vulnerability to falls. Furthermore, Vincenzo et al. (2022) demonstrated that educational programs based on self-care and awareness models contribute to greater adherence to prevention strategies and the enhancement of hospital safety.

Nursing teams play a fundamental role in the early identification of risk factors and the implementation of preventive measures related to hospital falls. Dos Santos (2024) emphasized that safe nursing care is directly associated with the reduction of adverse events related to falls. Furthermore, Das Graças Pires et al. (2024) emphasized that the continuous role of nursing in clinical monitoring, patient guidance, and environmental surveillance constitutes an important tool for in-hospital prevention.

In the context of intensive care units and emergency departments, risks related to patient safety become even more complex due to the clinical severity of the patients’ conditions and their high dependence on care. De Barros and Ribeiro (2024) emphasized that critically ill patients are more vulnerable to adverse events, including falls, due to the use of invasive devices, sedation, and functional limitations. Similarly, Diz and Lucas (2022) highlighted the need to strengthen safety strategies in urgent care and emergency hospitals.

Additionally, recent studies have been incorporating new technologies and predictive models for the early identification of the risk of hospital falls. Belso-Garzas developed machine learning-based models to predict the risk of falls in hospitalized patients, while Dormosh et al. (2022) validated electronic predictive models using clinical records from primary care and hospital settings. These tools represent a significant advance toward personalized care and the prevention of adverse events related to patient safety.

Given the high clinical, epidemiological, and care-related relevance of falls in the hospital setting, it is essential to gather and critically analyze the available scientific evidence regarding the main risk factors, preventive strategies, and impacts related to patient safety. Thus, this systematic review aims to synthesize the findings of the contemporary literature on hospital falls, contributing to the strengthening of safe care practices and the implementation of evidence-based preventive protocols.

Hypotheses

Main Hypothesis

The implementation of institutional patient safety protocols and evidence-based preventive strategies significantly reduces the risk of falls in the hospital setting, especially among elderly and clinically vulnerable patients.

Secondary Hypotheses

1. Hospitalized patients who are elderly, clinically frail, have functional limitations, and multiple comorbidities are at higher risk of in-hospital falls.
2. The presence of factors such as polypharmacy, use of sedative medications, cognitive impairments, and mobility deficits is directly associated with an increased incidence of hospital falls.
3. The continuous involvement of the multidisciplinary team, especially nursing staff, contributes to the early identification of risk factors and the reduction of adverse events related to falls.
4. The use of standardized protocols for fall assessment and prevention improves patient safety and reduces complications resulting from in-hospital events.
5. Educational interventions targeting healthcare professionals and patients increase adherence to preventive measures and promote greater awareness of the risk of falls.
6. Patients admitted to intensive care units, emergency departments, and high-complexity units are at higher risk for hospital falls.
7. Technological tools and predictive models based on artificial intelligence and electronic records contribute to better stratification of fall risk in hospitalized patients.
8. The adoption of patient-centered strategies promotes greater active participation in preventive measures and improves hospital safety indicators.
9. Hospital falls are associated with longer hospital stays, increased hospital costs, higher morbidity, and reduced quality of care.
10. The implementation of institutional patient safety programs contributes to an overall reduction in adverse events related to falls in the hospital setting.

General Objective

To analyze, through a systematic review of the literature, the main scientific evidence related to patient safety and factors associated with the risk of falls in the hospital setting, emphasizing preventive strategies, care protocols, and clinical impacts resulting from these adverse events.

Specific Objectives

1. To identify the main risk factors associated with falls in hospitalized patients.
2. To assess the influence of advanced age, clinical frailty, comorbidities, and functional limitations on the occurrence of in-hospital falls.
3. Investigate the relationship between polypharmacy, the use of potentially sedative medications, and an increased risk of falls in the hospital setting.
4. Analyze the role of the multidisciplinary team, especially nursing staff, in the prevention and monitoring of hospital falls.
5. To assess the effectiveness of institutional protocols and preventive strategies aimed at patient safety.
6. To assess the impact of educational interventions targeting healthcare professionals and patients on the reduction of fall-related events.
7. Investigate the use of technologies, predictive scales, and risk assessment models applied to the prevention of hospital falls.
8. Analyze the main clinical outcomes associated with hospital falls, including increased length of stay, physical complications, morbidity, and mortality.
9. To evaluate the contribution of patient safety programs to improving the quality of care in the hospital setting.
10. To synthesize current scientific evidence regarding the most effective strategies for fall prevention and the strengthening of evidence-based hospital safety.

Methodology

This study is a systematic literature review conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020), with the objective of analyzing scientific evidence related to patient safety and the risk of falls in the hospital setting.

The literature search was conducted in the PubMed/MEDLINE, Scopus, Web of Science, Embase, Virtual Health Library (VHL), SciELO, and Cochrane Library databases, covering studies published between January 2010 and March 2026. Additionally, a manual search was performed in the references of the selected articles to further identify relevant studies related to the topic.

For the search strategy, controlled vocabulary terms from the Medical Subject Headings (MeSH) and Descritores em Ciências da Saúde (DeCS) were used, combined with the Boolean operators “AND” and “OR.” Among the main terms used were: “Patient Safety,” “Falls,” “Hospital Falls,” “Fall Prevention,” “Risk Factors,” “Inpatients,” “Hospitalization,” “Nursing Care,” “Accidental Falls,” and “Safety Management.”

The inclusion criteria comprised original articles, systematic reviews, meta-analyses, observational studies, clinical trials, and guidelines published in Portuguese, English, and Spanish that addressed risk factors, prevention, institutional protocols, patient safety, and falls in the hospital setting. Studies involving adult and elderly patients hospitalized in clinical, surgical, intensive care, emergency, and inpatient units were included.

Duplicate articles, studies without access to the full text, publications not directly related to the topic, studies conducted exclusively in home settings or long-term care facilities, and studies with low methodological quality following critical analysis were excluded. Editorials, letters to the editor, simple abstracts, and studies without adequate methodological descriptions were also excluded.

The study selection process was conducted in three stages: identification, screening, and eligibility. Initially, articles found in the databases were exported to a bibliographic manager, and duplicates were subsequently removed. Next, two independent reviewers read the titles and abstracts to select potentially eligible studies. Subsequently, the selected articles were evaluated in full, considering the previously defined inclusion and exclusion criteria . Disagreements between reviewers were resolved by consensus.

Data extraction included information regarding authors, year of publication, methodological design, study population, identified risk factors, preventive strategies used, institutional protocols applied, main clinical outcomes, and study conclusions. The data were organized into summary tables and comparative tables to facilitate the analysis of scientific findings.

The methodological quality of the included studies was assessed using specific instruments appropriate to the methodological design of each study, considering risk of bias, consistency of results, clinical applicability, and scientific relevance. The results were analyzed descriptively and narratively, seeking to identify convergences, divergences, and gaps in the literature regarding patient safety and the prevention of hospital falls.

The study selection flowchart was developed according to the PRISMA 2020 model, detailing the stages of identification, screening, eligibility, and final inclusion of the analyzed articles.

Results

The selection process for the studies included in this systematic review was conducted in accordance with the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, ensuring greater methodological rigor, scientific transparency, and standardization of the identification, screening, eligibility, and inclusion stages for the analyzed articles. The PRISMA flowchart presented here details all the steps taken during the search and selection process of the literature related to patient safety and the risk of falls in the hospital setting.

Initially, 684 records were identified in the major scientific databases, including PubMed/MEDLINE, Scopus, Web of Science, Embase, Cochrane Library, Virtual Health Library (VHL), and SciELO. After removing duplicates, 497 studies remained for analysis of titles and abstracts. At this stage, 301 articles were excluded because they were not directly related to the review’s topic or did not meet the previously established eligibility criteria.

Subsequently, 196 articles were selected for full-text reading and detailed evaluation regarding methodological and scientific relevance. During the eligibility stage, 124 studies were excluded for various reasons, including the absence of a specific focus on hospital falls and patient safety, the use of experimental models, studies conducted outside the hospital setting, case reports, the absence of relevant clinical data, and the unavailability of the full text.

At the end of the selection process, 72 studies were included in the qualitative synthesis of this systematic review. The selected articles allowed for a comprehensive and y analysis of the main risk factors associated with hospital falls, preventive strategies, institutional patient safety protocols, educational interventions, and clinical impacts related to in-hospital adverse events, contributing to the strengthening of evidence-based care practices and the improvement of the quality of hospital care.

The main findings also indicated that standardized protocols, educational interventions, and the use of predictive scales contribute significantly to reducing the incidence of falls and strengthening the hospital safety culture. There has been a growing incorporation of technological models and patient-centered strategies to improve the prevention of adverse events related to falls. Thus, Table 1 presents the main studies related to risk factors, patient safety, and preventive strategies in the hospital setting.

Table 1 – Key studies related to patient safety and the risk of falls in the hospital setting

The studies presented in Table 1 demonstrate that hospital falls represent a significant challenge related to patient safety and the quality of care. There was a predominance of research aimed at identifying clinical and functional risk factors, especially in elderly, frail patients, and those on multiple medications. Additionally, the articles highlighted that environmental factors, structural limitations, and failures in adherence to institutional protocols also contribute significantly to the occurrence of adverse events related to falls.

Table 2 compiles studies primarily related to preventive strategies, institutional protocols, educational interventions, and multidisciplinary approaches aimed at reducing the risk of falls in the hospital setting. The analyzed articles demonstrate that fall prevention depends not only on the identification of clinical risk factors but also on the implementation of structured organizational measures, the strengthening of a safety culture, and the active participation of patients and healthcare professionals. There has been a growing emphasis on educational programs, the use of predictive scales, and patient-centered strategies as fundamental tools for improving hospital safety.

Furthermore, the included studies highlighted that institutional adherence to preventive protocols is directly associated with a reduction in adverse events, shorter hospital stays, and improved quality of care. The literature also showed that ongoing educational interventions targeting multidisciplinary teams significantly contribute to greater recognition of risk factors and the strengthening of evidence-based care practices.

Table 2 – Studies related to preventive strategies and safety protocols for reducing hospital falls

The studies presented in Table 2 demonstrate that fall prevention in the hospital setting depends directly on the integration of institutional protocols, interprofessional education, and active patient participation in care. A predominance of research related to the implementation of preventive programs, the use of risk assessment scales, and the strengthening of an organizational culture focused on patient safety was observed. Furthermore, the articles demonstrated that continuous educational strategies directed at healthcare teams significantly contribute to greater adherence to preventive measures and a reduction in in-hospital adverse events.

Another relevant aspect identified was the growing incorporation of patient-centered models and predictive technological tools for the individualization of preventive care. The results reinforce that the implementation of standardized protocols, combined with continuous monitoring of hospital safety indicators, has a positive impact on reducing the incidence of falls, improving the quality of care, and strengthening evidence-based practices in the hospital setting.

The studies included in this systematic review demonstrated that falls in the hospital setting can lead to significant clinical, functional, and psychological consequences for patients, especially among the elderly, frail individuals, and patients with multiple comorbidities. Injuries resulting from falls vary widely in severity, ranging from minor abrasions to complex fractures, h , traumatic brain injury, and death, contributing significantly to increased length of hospital stay, hospital costs, and impaired quality of life.

The reviewed literature showed that fractures, contusions, and head injuries are among the main complications associated with in-hospital falls. Furthermore, several studies highlighted that patients who suffer falls are at higher risk of functional loss, limited mobility, recurrent fear of new falls, and the need for prolonged rehabilitation. The graph below summarizes the main health consequences observed in the selected studies.

The graphical analysis demonstrates a predominance of abrasions and contusions among the most frequently reported injuries in the studies, followed by fractures and muscle injuries. Although less frequent, head injuries and hemorrhages were more strongly associated with serious outcomes and the need for specialized interventions. It was also observed that fall-related deaths, although less prevalent, represent an important indicator of the severity of these adverse events in the hospital setting.

The findings reinforce the need to implement structured preventive protocols, continuously monitor high-risk patients, and strengthen multidisciplinary strategies focused on hospital safety. Thus, fall prevention not only reduces physical adverse events but also directly contributes to improving the quality of care, reducing hospital costs, and strengthening the patient safety culture.

Figure 1 below shows the distribution of the main clinical consequences related to falls in the hospital setting observed in the studies included in this systematic review. The graph illustrates the relative frequency of the injuries most commonly associated with in-hospital falls, highlighting the predominance of abrasions, contusions, and fractures among affected patients.

Furthermore, it is observed that head injuries, hemorrhages, and deaths, although less frequent, are associated with outcomes of greater clinical severity and functional impact, especially in the elderly and frail patients. These results reinforce the importance of implementing structured preventive protocols and continuous monitoring of hospitalized patients at higher risk of falls.

The findings demonstrate that hospital falls are not merely isolated events but significant factors associated with increased morbidity, prolonged hospital stays, the need for rehabilitation, and higher hospital costs. Thus, multidisciplinary preventive strategies and early interventions remain essential for strengthening patient safety and improving the quality of care in the hospital setting.

Figure 1 – Main Clinical Consequences of Hospital Falls in Inpatients: Summary of Included Studies

The studies included in this systematic review demonstrated that hospital falls have a significant economic impact on healthcare systems, substantially increasing the clinical, operational, and administrative costs of hospitals. Among the main factors associated with increased costs are prolonged hospital stays, the need for surgical treatment of fractures, physical therapy rehabilitation, use of intensive care units, and the performance of additional tests.

In addition, fall-related events can generate additional indirect costs, including legal proceedings, prolonged work absence, and the need for ongoing multidisciplinary support. The graph below presents a summary of the main economic components associated with hospital falls identified in the analyzed studies.

The graphical analysis shows that increased length of hospital stay represents the main economic component related to hospital falls, followed by costs associated with fracture treatment and physical therapy rehabilitation programs. A significant impact was also observed regarding intensive care and imaging tests, especially in patients with head injuries and severe injuries resulting from falls.

The findings reinforce that the implementation of evidence-based preventive strategies has not only a positive clinical impact but also significant potential for reducing hospital costs. Thus, structured preventive protocols, continuous monitoring of high-risk patients, and strengthening of patient safety practices represent essential measures for improving the quality of care and optimizing institutional resources.

Figure 2 – Main Economic Impacts of Hospital Falls: Summary of Costs Reported in the Literature