Issue/Issue of Concern Falls are the second most common adverse event in healthcare institutions after medication errors, and an estimated 30% of hospital falls result in serious injury. The severity of this problem led the Joint Commission to make reducing the risk of injury from falls a national patient safety goal for hospitals in 2009 (AHRQ, 2006). Falls are a leading cause of hospital-acquired injuries and often prolong and complicate hospital stays and result in poor quality of life, increased costs, and unexpected admissions to long-term care facilities. Changes in health care financing in the 1990s were accompanied by a series of cost-cutting measures at hospitals across the United States. Common cost-cutting strategies included reducing the total number of nursing hours per patient per day and reducing the percentage of hours provided by registered nurses (RNs), the highest-paid group. The reduction in staff led to widespread concern that acute patient care would be affected. In response to concerns about staffing and quality of care, the American Nurses Association (ANA) launched the Patient Safety and Nursing Quality Initiatives in 1994 to address the impact of healthcare restructuring on patient care and nursing . To facilitate the initiative, ANA established the National Database of Nursing Quality Indicators (NDNQI) in 1997, with two objectives: (1) develop a database that supports empirical monitoring of the impact of nursing staffing on patient safety and on the quality of care in all sectors. of the nation, and (2) provide individual hospitals with a quality improvement tool that includes national comparisons of nurse staffing and patient outcomes with similar hospital incidents, depending on the patient population studied (Hitcho, 2004). Rates vary from 1.9 to 18.4 falls per 1,000 hospital days depending on the type of organization and, according to a study by the National Council on Aging, 30% of these incidences result in serious injuries (Stevens, 2004). Another significant consequence of falls is that they are costly and contribute to increased healthcare spending. An estimate of the average DRG payment for injuries sustained by a fallen patient is $25,643 (Hart, Chen, Rashidee, & Sanjaya, 2009). This is significant as with the development of a “pay for performance” climate initiated by CMS, hospitals now have a significant monetary interest in reducing the number of fall-related injuries. The CDC estimates that the cost of fall injuries will exceed $23 billion in the next few years (Tzeng, 2008).