Purpose: Since 1993, elderly in Taiwan had reached 7% of the total population and entered aging society. The estimated population will reach 14% aged society in 2018. Prompting medical institutions face and ponder hospitalized elderly (≧65-year-old) ethnic care. This project's aim is to build a systematic fall notification, monitoring, improvement and learning systems. Reducing injury of hospitalized elderly caused by the fall. Methods: A large hospital via reaching consensus and supporting by its executives composed a committee and building a reporting system for countering the notification of the fall of the elderly populations. Composition of the committee: By executives leading and different medical professionals to compose a committee in order to keep events tracking. Bulletin: When hospital patients fall event occurs, any employee should inform. Monitoring: Daily fall event notification should be inspected by dedicated person. Analysis: According to the modified from South Wales, Australia developed when the event Severity Assessment Code (SAC) Matrix analysis the degree of injury and norms SAC1, 2 level events should be included in the analysis results to improve execution. Improvement: Import diverse practices, Implement the improvement strategies in light of single event. Learning: Improve the act during the Commission report. Conduct organized learning by the event. The measurement indicator is a certain large hospital informed the fall event compare the value of the national peer. Results: January 2010 to December 2012, the certain large hospital had informed the total number of 12,325 pieces, of which there are 1,356 pieces fall event. Accounting for 11.0% informed, compared to the national peer values (27.5%) is lower; Among hospitalized elderly population has 55.5%, compared to the national peer value (44.7%) is higher; harm resulting from falls has 35.8% compared to the national peer values (49.4%) is lower; SAC1 level events accounted for 0.0%, SAC2 level accounting 0.9%, compared to the national peer value (SAC1 level 0.1%, SAC2 level 2.2%) is lower. Conclusions: This certain large hospital showed that even though hospitalized elderly population accounted for 55.5% is higher than the national rate of peer values by implementing a systematic fall system, accounting for a fall event notification rate (11.0%) and injuries resulting from falls accounting rate (35.8%) was lower than the national peer values. Every single injuries cause by fall cannot be ignored. It is recommended to import information to create an effective individualized preventive measure.