The incidence of the fell is one of the hospital serious problems, especially in the hospitalized patient. The number of fall incidence is one of the main indicators in patient safety and hospital quality. Qualitative study with phenomenology approach was conducted to explore factors affecting the risk of fall in pediatric patients. Four nurses consist of two team leaders and two associate nurses participated in in-depth interviews. The findings from the interviews were triangulated in some process including an interview with the head of an inpatient installation, supervisor, and patient family, participative observation, documentation of form Humpty Dumpty and operational standard prevent the risk of fall. The result data was analyzed with the content analysis method and concluded with a fish bone. Four themes emerged from the analysis: knowledge, human resources, environment, and facilitation. Bad implementation of operational standard procedure, heavy workload of a nurse with unbalance ratio between patient and nurses, the slippery floor, unfixed bedside rails, and unavailability of patient bell have a role in affecting the risk of fall. This study suggests to held fall prevention education, make a review of nurse’s workload with recalculate the ratio of patient and nurse and upgrade the hospital facilitation and environment situation.