Open AccessInpatient falls are considered 'never events' that may result in increased costs and adversely affect quality of care. This study describes and analyzes characteristics of inpatient falls collected on a ‘Post Fall Huddle/Event Report’ form used by nursing and Risk Management. Data from a convenience sample of 182 falls were collected over a six month period. Analyses included descriptive and regression models on outcomes of injury and length of stay. Incontinence/elimination, antihypertensive medications, higher census, and any medication change, suggested associations with injury or length of stay. Based on the results several strategies were implemented by CNSs to include in-depth review of circumstances surrounding the fall; education of staff for consistency in the fall protocol; reinforcement of purposeful hourly rounding; and the need for increased objectivity on the Post Fall Huddle/Event Report form. Post implementation the average annual number of inpatient falls decreased by 50%.