Abstract: Objective: To analyze the causes of fall, make and implement relevant improvement measures. Methods: We delivered retrospective analysis of causes of 46 fall cases in our hospital in 2015. The reasons were nurses' improper assessment or not timely assessment, poor effect of health education about drug and physical activity among patients with physical disabilities, nurse visits not in place, and patients' poor compliance, etc. In order to reduce the incidence of falls, we established improvement project, including establishment of fall team, fall assessment and health education training, formulating health education manual, standardizing 5p patrol mode, using mobile logo and fall informed consent, and using quality control method to ensure the effectiveness of the project measures. Results: There were 29 fall cases in 2016, and the incidence was 0.58 per thousand. Compared to 2015, the incidence in 2016 decreased significantly (P<0.05). The incidence of severe damage reduced significantly from 43.5% to 10.3%. The regression analysis showed that improvement project was a protective factor for fall patients with severe damage. Conclusion: Through the analysis of the causes of fall adverse events, we can use improvement project to reduce the incidence of falls, reduce the degree of injury, ensure the safety of patients, and improve the quality of nursing.