Falls are a persistent patient safety concern throughout healthcare facilities, yet prevention efforts often focus on monitored clinical settings rather than the complex environments patients navigate before and after outpatient care. This case study examines escalator use and fall risk in a large academic medical center through a human factors assessment of wayfinding, signage, and environmental design. The objective was to identify opportunities to reduce unsafe navigation decisions by improving access to safer vertical transport options. A human factors safety engineer conducted an observational environmental audit across interconnected buildings, parking structures, and patient access pathways. The assessment qualitatively evaluated sign visibility, decision points, route complexity, and anticipated user behavior. Findings indicate that escalators were frequently more visible and convenient than elevators, while elevator routes were less prominent, inconsistently labeled, and often located along less intuitive pathways. These conditions contribute to navigation uncertainty and may increase reliance on higher-risk options, particularly for individuals with mobility limitations, fatigue, or unfamiliarity with the facility. Proposed interventions include enhancing the visibility and timing of elevator signage, incorporating destination-confirmation cues, implementing progressive wayfinding systems, and reinforcing navigation guidance through patient-facing workflows. This study demonstrates that wayfinding should be treated as a patient-centered safety system. Applying human factors principles to the design of healthcare navigation can improve decision-making, reduce preventable risk, and enhance the overall patient experience in complex care environments.

Keywords

Patient Safety, Systems Engineering, Healthcare Design, Hospital Navigation, Built Environment