In this episode of Hospital Medicine Unplugged, we tackle in-hospital falls—how often they happen, why they’re so devastating, and how to build a multifactorial, restraint-sparing prevention bundle that actually works at the bedside. We start with the scope: typical acute-care fall rates run 1.5–4.2 falls per 1,000 patient-days, with geriatric and medical units hit hardest. Up to half of fallers are injured; in older adults, major injuries are ~8× more common, with hip fractures, subdurals, and ICH driving longer LOS, readmissions, cost, litigation, and loss of trust. Add in Joint Commission sentinel event rules and CMS non-payment for fall injuries—and you’ve got a must-fix safety problem. Then we clean up the language: hospital falls as any unexpected descent to floor/lower level; we sort anticipated physiological (gait, weakness, meds), unanticipated physiological (delirium, new illness, syncope), and accidental (environmental). We walk through injury severity from none → minor → moderate → Major A/B/C → death, and zoom in on high-risk contexts: toileting, bed-exit, transfers, ambulation, peri-procedural. Next, we hit what’s modifiable in hospital:• Psychotropics and other FRIDs (benzos, antidepressants, antipsychotics, sedatives, opioids, insulin, antihypertensives, high ACB burden)• Orthostatic hypotension, gait/balance deficits, muscle weakness, vision loss• Delirium, sleep disruption, pain, and continence issues• Environmental and care-related factors: clutter, lighting, equipment, staffing, and unsupervised toileting For screening and risk strat, we ditch scored “fall risk” stickers and lead with brief admission screening (think CDC STEADI 3 questions) plus automatic high-risk flags (recent falls, injury, frailty, gait impairment). Anyone who screens positive gets multifactorial assessment: meds, orthostatics, gait/balance (TUG), cognition/delirium, vision, feet/footwear, continence, ADLs, and environment—using tools like Morse or Johns Hopkins to structure, not replace, clinical judgment. When a fall happens, we move fast: ABCs, head-to-toe for occult injury, neuro check, hip and spine, orthostatics, targeted labs and imaging. We ask the framing question: “If this were a healthy 20-year-old, would they have fallen?” If not, we hunt for underlying pathology—arrhythmia, infection, stroke, medication toxicity—and loop in PT/OT early. The core of the episode is the multifactorial bundle:• Medication review & deprescribing FRIDs; reschedule diuretics/antihypertensives away from night• Supervised exercise & mobility: strength, balance, functional training; no “bed rest by default”• Environmental optimization: lighting, clutter, bed height, grab bars, walking aids within reach• Delirium prevention/management: orientation, sleep hygiene, sensory aids, early mobilization• Toileting protocols: scheduled voids, timely assistance, prioritize bathroom & bed-exit safety• Nutrition & vitamin D where indicated• Patient, family, and staff education as a high-yield, low-tech intervention We zoom in on special populations—very old, cognitively impaired, Parkinson’s, post-op, rehab and ICU patients—where falls are frequent and injuries severe. Here we stress person-centered care, care-partner involvement, sustained exercise, and balancing the tension between mobility and risk aversion. Then we tackle the controversies: physical restraints, bed/chair alarms, sitters, and high-tech sensors. We review why the evidence shows little benefit and real harm—more delirium, more device removal, more meds, longer stays—and how guidelines are shifting towards least-restraint, engagement-based models instead of “alarm everything.” We close with the post-fall and QI playbook: standardized post-fall assessment, a quick bedside huddle, unit-level root cause analysis, and using tools like Fall TIPS-style bedside plans to translate risk factors into visible, actionable precautions. We outline how to build a falls bundle into yo