Event-based safety governance and the systematic neglect of functional decline: a case for rebalancing quality measurement in the care of older adults.

Falls prevention is a cornerstone of quality improvement in the care of older adults, yet the metrics through which it is operationalised warrant scrutiny. Current quality frameworks in acute and post-acute settings overwhelmingly treat falls as discrete sentinel events while treating functional decline as a background condition unworthy of equivalent measurement. This commentary identifies this asymmetry as a distinct governance problem, which we term event-based safety governance: the systematic privileging of countable adverse events over longitudinal harms in quality oversight. In this context, governance refers to the regulatory, reporting and performance measurement systems that shape organisational accountability and clinical priorities. Previous authors have described the clinical tension between promoting mobility and preventing falls. We advance that discussion by arguing that the problem is not merely clinical but structural: the measurement architecture itself generates defensive practice by making falls visible to institutional accountability while rendering immobility-driven decline invisible. We propose that functional trajectory monitoring, embedded alongside fall event reporting, would correct this imbalance by making the harms of inactivity organisationally legible. Until quality measurement in the care of older adults accounts for what patients lose through enforced stillness, often an unintended consequence of system-level incentives, as rigorously as it accounts for what happens when they fall, clinical judgement will remain subordinate to institutional risk avoidance. We propose three practical reforms: routine functional trajectory monitoring, integration of mobility outcomes into organisational quality dashboards and explicit recognition of mobilisation as a safety-aligned clinical activity.