UHC conducted an analysis of more than 25 000 patient fall reports entered into the UHC Patient Safety Net incident reporting tool. Gaps were found in the completion of fall risk assessments, the ability of tools to accurately assess risk, and prevention strategies in particular inpatient units and emergency department. Common factors in falls resulting in major harm or death included age more than 80 years, altered mental status, ambulation (often without assistance), toileting, and diuretics and anticoagulants.