"The road to hell is paved with good intentions" - the cognitive bias of immobility in in-patients at risk of falling.

Patient falls are one of the most common adverse events reported in hospitals1. Although preventable hospital falls have been decreasing over the past years, approximately 1 in 10 falls results in serious injury2. Besides, inpatient falls can result in significant physical and economic burdens to the patients (increased injury and mortality rates and decreased quality of life) and to medical organizations (increased length of stay, medical care costs, and litigation)1,2. Consistent concerns aimed at reducing this problem have led hospitals to adopt very heterogeneous guidelines for fall prevention3. These guidelines usually include (1) identification of patients who are at high risk of falling and (2) decisions to which attitude of fall prevention strategies to use to reduce fall risk1,2. However, this approach may had led to a confused “correct approach” to fall prevention in specific settings, since the lack of clarity of prevention guidelines may add to the cognitive burden of patient care and potentially increases in-hospital patient risk. First, the use of fall risk prediction tools is widespread, but their value in hospital fall prevention interventions is questionable4. In this context, it is important to distinguish between fall risk assessments and fall prediction or screening tools. Risk assessments usually consist of a checklist of risk factors for falls but do not provide a score or value for the patient’s fall risk1. The lack of evidence supporting the use of predictive tools led National Institute for Health and Care Excellence and the Agency for Healthcare Research and Quality to recommend a caution in the routine use of fall prediction tools1. Despite this, fall risk screening tools are frequently used to identify patients for intervention and are recommended and required by Healthcare International Quality Agencies5. Second, falls in hospitals are different from falls in general, community-dwelling adult populations3. Inconsistencies in risk factors for falls have been identified between hospitalized and nonhospitalized older adult populations1. The hospitalized patients are in unfamiliar environments and routines; present pain; are commonly under the influence of psychotropic drugs, anesthetics, or opioid analgesics; are connected to drains, tubes, or venous catheters; and have a loss of locus of control in performance of personal activities and a physical dependency on staff. In this context, a recent meta-analysis identifies 11 risk factors for falls in hospitalized patients with cancer, including age, history of falls, opiates, benzodiazepines, steroids, antipsychotics, sedatives, radiation therapy, chemotherapy, the use of an assistive device, and length of hospitalization6. Another problem is that the trials have not preferentially evaluated hospitalized patients1,3. When evaluated only hospitalized patients, there were no significant reduction of risk of falls and combined clinic-level quality improvement strategies, patient-level quality improvement strategies, and multifactorial assessment and treatment relative to usual care (OR 0.78 [95%CI 0.33–1.81]) or with combined patient-level quality improvement strategies and exercise relative to exercise alone (OR 1.12 [95%CI 0.38–3.25])7. Third, interventions that prevent falls may not prevent injurious falls3. Injurious falls, particularly those requiring provision of additional healthcare services, have been found to be the key driver of overall “cost per fall” estimates. As injurious falls occur at a lower frequency than total falls, individual studies are rarely powered adequately to identify an effect on this outcome. However, one could argue that if falls are reduced, injurious falls should also reduce by a similar magnitude; thus, a reduction in falls would be seen as beneficial. Finally, the identification of a patient at risk of falling cognitively leads the hospital staff to mobilize less the patients. Falls also lead to anxiety and distress among caregivers and relatives who perhaps believe that “something should have been done” in an apparent place of safety to prevent the falls and that “someone