Falls With Injury

Identifying Attributes

Care Settings
Hospital Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS)
Type of Quality Indicator
Outcome
IOM Quality Dimension
Safety
Setting-Specific Domain
Falls and Major Injuries

Defining Attributes

Definition

This ratio measure assesses the number of inpatient hospitalisations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients aged 18 years and older.

Numerator

The numerator is inpatient hospitalisations where the patient has a fall that results in moderate or major injury. The diagnosis of a fall and of a moderate or major injury must not be present on admission. Examples of moderate injuries include lacerations, open wounds, dislocations, sprains, and muscle strains. Examples of major injuries include fractures, closed head injuries, and internal bleeding. The time period for data collection is during an inpatient hospitalisation, which are defined as beginning at hospital arrival including time in the emergency department or observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other.

Denominator

Inpatient hospitalisations for patients aged 18 and older with a length of stay less than or equal to 120 days that ends during the measurement period. Inpatient hospitalisations where the patient has a fall diagnosis present on admission are excluded from the denominator. Measure observation associated with the Denominator: The total number of eligible days across all encounters which match the initial population/denominator criteria.

Exclusions

The denominator exclusion is inpatient hospitalisations where the patient has a fall diagnosis present on admission. The time period for data collection is during an inpatient hospitalisation, which is defined as beginning at hospital arrival including time in the emergency department or observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other.

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

None

Collection and Reporting Attributes

Type of Data Collection
Administrative data
Data Collection Methods

Hospitals collect EHR data using certified electronic health record technology (CEHRT). The MAT output, which includes the human readable and XML artifacts of the clinical quality language (CQL) for the measure are contained in the eCQM specifications attached. No additional tools are used for data collection for eCQMs.

Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods
Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
No

Source and Reference Attributes

Evidence Source
Technical Specifications
Link to Measurement Tools
Domain
Falls and Major Injuries
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
Yes
Can the Quality Indicator be Readily Implemented at a Population Level in Australia Given its Current Data Landscape?
Yes. Data exists, with high coverage.
Identified by PHARMA-Care Project
No
Upload Date
23 July 2025