Serious Patient Falls Increase During Discharge: Emerging Liability Risks and Clinical Duties

The relationship between hospital discharge practices and patient safety has long been discussed in clinical literature, but recent findings from the Pennsylvania Patient Safety Authority bring the issue into sharper focus for both healthcare providers and the lawyers who represent patients and institutions. In 2024, the Authority reported 35,450 patient falls across the state, a number significant on its own but even more instructive when the patterns beneath it are examined. Among those patterns, one stands out with particular medical and legal implications: patients are more likely to suffer a serious injury from a fall during the period surrounding discharge than at any other time during hospitalization. For attorneys practicing in the medical negligence and risk-management space, this finding underscores the need for deeper scrutiny of discharge protocols, adequacy of fall-risk assessment, and the continuity of care responsibilities inherent in a provider-patient relationship.

The Authority’s review found that 7.5 percent of patients who fell during the discharge period sustained a serious injury. By contrast, only 2.9 percent of falls occurring at other times during hospitalization led to serious harm. Statistically, this disparity is highly significant (p<0.0001). In litigation terms, it sharpens the question of foreseeability. If a substantial body of evidence demonstrates that patients are more vulnerable during discharge activities, then providers have constructive notice of an elevated risk and a corresponding duty to implement targeted safeguards. From the medical perspective, the discharge period represents a transition of physical, cognitive, and emotional demands on patients. From the legal perspective, it represents a foreseeable zone of heightened danger where failures in protocol, communication, or supervision may satisfy the elements of negligence.

Demographic data from the Authority’s report further clarify the risk profile. Nearly seventy percent of patients who fell were age sixty-five or older. Older adults also sustained more severe injuries during discharge-related falls, with 8.6 percent suffering significant harm compared to 5.2 percent among younger patients. Comorbidities, polypharmacy, impaired mobility, and post-procedure weakness commonly associated with older populations are well-documented contributors to fall risk. For lawyers evaluating a potential claim, these demographic indicators become important in assessing whether the hospital’s fall-prevention plan adequately accounted for the known vulnerabilities of particular patients. A facility that fails to incorporate age-specific risk factors into its discharge procedures may be vulnerable to claims that it deviated from the applicable standard of care.

Equally informative is the fact that where fall history was available, more than two-thirds of patients who fell were already identified as “at risk” for falls. Half of the patients had a documented history of previous falls. Clinically, a prior fall is among the strongest predictors of future falls. Legally, these statistics contribute to the argument that a fall during discharge is not an unforeseeable accident but a preventable event when proper precautions are ignored. When an at-risk patient is left to dress independently, pack belongings, step into a shower, or enter a vehicle without supervision or physical support, the foreseeability of harm strengthens the basis for liability. These are moments that predictably tax a patient’s balance, stamina, and spatial awareness—especially when compounded by pain, medications, anxiety, and the cognitive load of leaving the hospital.

The types of falls observed provide further insight into the mechanics of these events. Ambulation-related incidents were the most frequent, but a significant proportion of patients were found on the floor after attempting unsupervised activities. Transferring from one position to another, sitting in a chair or wheelchair, and toileting were also common scenarios. Although each category reflects routine movements within the hospital environment, the discharge context amplifies their complexity. Patients may attempt to move more quickly, carry personal items, or navigate unfamiliar spaces as they prepare to leave. The emotional desire for independence at discharge can lead to risk-taking, especially if staff communication is unclear or delayed.

Perhaps the most striking finding is that 20.6 percent of the documented falls occurred during activities directly related to discharge rather than routine inpatient care. This subset involved dressing, packing belongings, showering or washing, and entering a vehicle—a cluster of actions that require coordination, balance, and physical exertion. These activities are physiologically demanding even for healthy individuals. For hospitalized patients, especially those recovering from surgery, under the influence of sedating medications, or coping with mobility limitations, they present a measurable and predictable risk. In legal evaluations, these discrete discharge-related activities can be powerful markers of whether a provider adequately supervised the transition of care or prematurely shifted responsibility to the patient.

What makes these findings particularly relevant to lawyers is the broader context of fall-prevention research. The Joint Commission Center for Transforming Healthcare successfully reduced falls with injuries by 62 percent in one study by implementing what it described as “simple” safety measures. These included systematic fall-risk screening upon admission, ongoing patient education about fall prevention, scheduled assistance with toileting, and frequent rounding by nursing staff. These are not novel or resource-intensive interventions. They are well-established, evidence-based, and widely disseminated practices within the healthcare industry. Their effectiveness reinforces the argument that many falls—especially predictable discharge-related falls—are preventable with reasonable care.

For attorneys representing patients, this research helps frame questions about whether hospitals met the standard of care. Was a fall-risk assessment performed at admission? Was it updated at discharge? Did staff communicate the results to the patient and their family? Did nurses assist with ambulation during the discharge process? Were medications that could impair balance accounted for? Were mobility aids provided and explained? The answers to these questions often determine whether a facility acted reasonably or negligently. For defense counsel, these findings emphasize the need for robust documentation, interdisciplinary handoffs, and consistent implementation of discharge protocols to demonstrate compliance with recognized safety standards.

For hospitals, the study serves as a reminder that the duty to protect patients does not end when the discharge order is signed. The discharge process is an extension of the continuum of care and requires the same diligence as any other clinical stage. Providers who fail to recognize this extended duty may find themselves exposed to claims that their negligence contributed to preventable harm. Conversely, institutions that proactively incorporate fall-prevention strategies into discharge planning not only reduce liability but also improve patient outcomes and satisfaction.

Ultimately, the Pennsylvania Patient Safety Authority’s study offers both an evidentiary and conceptual shift. It reframes patient falls not as isolated events scattered across the inpatient experience but as concentrated risks clustered around a key transition point. For the legal community, understanding this clustering is essential. It