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Earlier this year, Clare Collins from Northumbria Healthcare NHS Foundation Trust gave a presentation at the Patient Safety Management Network (PSMN) meeting on how their Trust has aimed to improve patient safety though a project to remove caffeinated drinks. In this blog, Clare shares their journey and what they have learned about implementation, engagement, organisational readiness and sustainability.  From a practical idea to a patient safety movement What started as a simple question: “Could changing the type of tea and coffee routinely served on our wards improve patient safety?”, has evolved into a growing quality improvement programme with local, regional and international interest. As a team, we wanted to explore whether a small and practical change to everyday care could contribute to safer, calmer and more restorative ward environments. At Northumbria Healthcare NHS Foundation Trust, we developed the Decaf by Default initiative to explore whether routinely offering decaffeinated tea and coffee to patients could help reduce toileting related falls, improve sleep and hydration, and support calmer, safer ward environments. The project has since expanded across multiple inpatient settings, generated strong staff engagement, and prompted wider conversations around organisational readiness for cultural change in patient safety. Why consider going decaf? For many years, staff across our wards routinely offered caffeinated hot drinks to patients as the default option. While this was often seen as a normal part of care and comfort, emerging conversations within our Care for the Older Person community raised questions about whether this practice unintentionally contributed to avoidable harm. Several factors prompted further exploration: NICE guidance recommends reducing caffeine intake in relation to urinary incontinence and pelvic organ prolapse in women. Caffeine can increase urinary urgency and frequency, potentially increasing the risk of toileting-related falls. Caffeine may negatively impact sleep and contribute to agitation. Non-caffeinated drinks can support hydration, rest, recovery and overall wellbeing. A review of Datix reports also identified that approximately 25% of inpatient falls over a one-month period were related to toileting activities, particularly within older people’s services. This led us to consider whether a relatively small environmental and behavioural change could contribute to safer care. Building the foundations: organisational readiness and engagement One of the strongest themes highlighted through discussions at the PSMN meeting was that success depended less on the decaf itself, and more on organisational readiness, staff engagement and shared ownership. From the outset, we did not approach this as a top-down instruction. Instead, the project focused on creating curiosity, shared ownership and practical collaboration. With senior nursing support, we established a quality improvement multidisciplinary community to explore the issue collectively. Staff from a range of professions and settings contributed ideas, concerns and learning throughout the process. Importantly, we also connected with University Hospitals Leicester, who had previously undertaken similar work. This external collaboration provided valuable insight, reassurance and practical learning. Several factors helped support implementation: Clinical ownership Ward teams were encouraged to shape how the initiative worked within their own environments rather than applying a rigid model. This helped improve engagement and sustainability. Preserving patient choice The initiative was never about removing patient choice. Patients could still request caffeinated drinks if preferred. A Taste the Difference challenge helped staff and patients explore perceptions around decaffeinated drinks. While around 55% of participants noticed a taste difference, approximately 85% said they would be willing to switch once they understood the potential benefits. Consistent messaging Simple, practical education materials were developed for staff, patients and carers, including posters, conversations at ward level and patient information leaflets. For example, digital teams looked at incorporating brief health promotion messaging into discharge documentation: “While in hospital, you were given decaffeinated tea and coffee. It may help to continue this at home.” This will reinforce the intervention beyond admission and encourage patients and carers to consider whether continuing reduced caffeine intake at home might support sleep, continence, anxiety management or falls prevention. Communities of interest One of the most important learning points was the value of building communities of staff who were genuinely interested in improving patient safety. Enthusiasm and local leadership often became stronger drivers than formal instruction. As discussed during the PSMN presentation, staff ownership proved critical to successful implementation. Challenges and learning The project generated important discussions and learning. Questions raised during the PSMN presentation included whether rapid caffeine withdrawal effects had been observed. While no specific reports had been identified, the team acknowledged that individual caffeine intake prior to admission is often unknown. Alternative approaches, such as limiting caffeinated drinks to mornings only, were explored and trialled in one location by a member of the PSMN but were not found to be sustainable in practice. Another PSMN member reported that in their care home, although they had adopted the change successfully, they had not seen a reduction in toileting-related falls. This highlighted the importance of local context, fall data and ongoing evaluation over a longer time period. From local project to wider movement Following pilot work in 2024-2025, Decaf by Default was adopted Trust-wide in December 2025. Since then, interest has continued to grow across the region and beyond. The project is now being explored more widely through collaboration with: the regional NHS Alliance the North East and North Cumbria Integrated Care Board patient safety networks and quality improvement communities. There has also been increasing international interest in the concept as organisations look for low-cost, scalable interventions that may contribute to safer care environments. Alongside the Trust-wide rollout, work has also begun to extend the learning into care homes across Northumberland and North Tyneside. This has created opportunities to explore how similar approaches may support resident wellbeing and reduce risks associated with continence, sleep disturbance, anxiety and falls within community-based settings. A small community pilot project has been developed involving community nurses and Allied Health Professionals (AHPs). Participating staff carry supplies of decaffeinated tea and coffee within their clinical bags and are able to offer this as part of broader lifestyle conversations and personalised care interventions. The aim is not simply to replace drinks, but to encourage wider discussion around hydration, sleep, continence, falls prevention and anxiety management in a practical and accessible way during routine community contacts. What has perhaps resonated most strongly is that the project demonstrates how a relatively small cultural and environmental changes can stimulate wider conversations about patient safety, prevention and personalised care. Key reflections Looking back on the journey so far, several lessons stand out: Small changes can create meaningful conversations about patient safety. Organisational readiness matters as much as the intervention itself. Staff ownership and engagement are essential for sustainability. Preserving patient choice supports acceptability. Quality improvement requires curiosity, testing and adaptation. Simple interventions may have wider wellbeing benefits beyond their original aim. Most importantly, the initiative has highlighted the value of frontline teams identifying opportunities to improve care through practical, evidence-informed innovation. Related resources Go decaf! How a simple change on our wards could reduce falls, slips and trips What happened when we went decaf – the story so far How going decaf could boost patient safety by reducing falls in hospitals Patient flyer - go decaf How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. Do you have a patient safety initiative you would like to share more widely. We'd love to hear from you and share it on the hub. Share here (you will need to be a member of the hub and signed in) or email [email protected].

This one-day training session will equip delegates with the skills to manage and investigate different types off falls. The day will be case study led and delegates will have the opportunity to ask questions pertaining to their own area of practice. Different types of learning responses will be explored, such as PSII, AAR, Swarm Huddles and thematic reviews. KEY LEARNING OBJECTIVES What is a slip, a trip and a fall? Choosing different types of learning responses How to recognise the systemic, human, intrinsic and extrinsic factors associated with different types of falls Undertaking effective site visits Focus on organisational learning through systemic analysis Practical report writing skills Register hub members get at 20% discount. Email [email protected] for discount code.

At a recent Patient Safety Education Network meeting, Karen Male, ward leader at the University Hospital Southampton, gave a presentation on how she reduced falls on her ward. We asked Karen to share her journey and insights in a blog for the hub. The Patient Safety Education Network is a informal voluntary peer network for those in patient safety education and training roles. It provides a monthly drop-in session with guests to talk through issues of importance to those in patient safety education and training roles and now has over 470 members. You can find out about the network here. The challenge I joined the ward 14 months ago at a time when there was a high number of falls. In one year there was 72 falls, including four high-harm falls, and we would regularly have three falls a day. Falls prevention and staff confidence was low in the management and assessment of falls, and policies and procedures were not being followed. The ward layout was challenging—a corridor with three-bedded bays, long and narrow. Many of the patients were older and there had been a lot of Covid infections. My goal was simple: to reduce the falls in our ward. What I did I organised an entire ward awayday focusing on falls education, prevention, management of falls, and policies and procedures—everyone attended at the same time. This allowed the staff to discuss the way they worked ('work as done'). Back at the ward a Baywatch bay and a PHUDD scoring system was set up with the aim to reduce falls, particularly unwitnessed falls, by identifying if someone is high, medium or low risk of falling. The ward is a long corridor so one to two Baywatch bays are required. The PHUDD scoring system was used to identify those patients most at risk and to identify where they can go on the ward for the safest outcomes and if additional support is needed. It’s completed at least once daily for patients. On the PHUDD scoring system, 1 point was given to each question where the answer is yes. A point was added for any fall in the hospital. This was then used to decide which patient needed to be in the Baywatch bay. This score is on the handover and reviewed daily and at catch ups. Outcomes We have significantly reduced our falls—there has been 61.7% reduction in falls. There has been two long periods with no falls (one for a 48-day period and one for a 50-day period). Since the education day, we have had 1 or 2 falls a month rather than 5-11 falls every month. In the last 4 month we have had 6 falls instead of the potential 44. Staff are now educated on policies and procedure around the prevention of falls and the management of falls. Staff are proactive in the prevention of falls. Everyone knows that the Baywatch bay is the priority. And then everyone has their ends of the bay but we all cover each other. We have signs to say that’s it’s a Baywatch bay—for staff but also for relatives to say we can’t leave this bay. PHUDD score gives us evidence. You might have enough staff but we might have five patients with a particularly high score. So we have more staff around the bays to even it out where it’s needed. Night staff feel empowered to move patients who were most at risk to higher observation beds as they are the staff group most affected by falls on the ward. Bay nursing introduced handovers conducted outside of the bays, which enhanced the communication as opposed to being in an area away from the patients. We have completed a falls After Action Review and were praised for our significant improvement in post falls management and documentation. Senior management across our Trust have asked to learn more about the falls reduction plan. Barriers faced I met barriers. Staff were not acting in the way I wanted so I met resistance. But I was very honest with them. Told them what the consequences were. Got the most resistant on board first and then everyone else was easier. At the beginning the staff were demotivated and didn’t feel part of a team. We need to keep our teams valued and motivated. It’s an ongoing commitment to staff. We are always looking at how we can improve and asking staff what their ideas are. I think the biggest thing I did was look at what was my one main priority. And that’s what we focused on—falls. Now we are moving to pressure ulcers. If you pick one big thing to work on it’s easier. Give it a big focus and then, once sorted, move on to the next thing rather than trying to do everything at once. Next steps Training and education is essential—this has continued regularly from the ward leadership team. I’d like to do some simple quantification—more cost effective, efficient. PHUDD score gives us evidence. You might have enough staff but we might have five patients with a particularly high score. So we have more staff around the bays to even it out where it’s needed. We are now doing another nurse-led trial setting daily goals for patient mobility. We are very clear what the goals are, to increase mobilisation, and these goals are on the handover sheets for everyone to see. Further reading on the hub Yellow kits - an innovation to reduce the risk of falls in Accident and Emergency departments "The greatest part of this adventure has been the sharing of information." The Patient Safety Education Network one year on Implementing the aSSKINg pressure ulcer care bundle – a blog by Susan Martin Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? We would love to hear from you and share on the hub your journey. If you are a member, you can share directly on the hub or please contact [email protected] to discuss further.

This conference focuses on improving safety for hospice patients. The day will highlight best practice in improving safety in hospices, highlight new developments such as the implications of the new Patient Safety Incident Response Framework (PSIRF), and the new CQC Inspection Framework, and will focus on key clinical safety areas such as falls prevention, medication safety, reduction and management of pressure ulcers, nutrition and hydration, improving the response and investigation of incidents, preparing for onsite inspections and developing a compassionate culture in hospices. Register at https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-safety-hospices or email [email protected] hub members receive a 20% discount. Email [email protected] for discount code. Follow the conference on Twitter @HCUK_Clare #PSHospices

This Hospital at Night Summit focuses on out of hours care in hospitals delivering high quality safe care at night. Through national updates, networking opportunities and case studies this conference provides a practical guide to delivering a high quality hospital at night, and moving forward during and beyond the Covid-19 pandemic. The conference will also focus on improving staff well-being at night and reducing fatigue. Attending this conference will enable you to: Network with colleagues who are working to improve Hospital at Night Practice Learn from developments as a results of Covid-19 Improve your skills in the recognition management and escalation of deteriorating patients at night Understand and evaluate different models for Hospital at Night Examine the role of task management solutions for Hospital at Night, including handover and eObservations Ensuring effective and safe staffing at night, including adequate breaks Examine Hospital at Night team roles, competence and improve team working Improving safety through the reduction of falls at night Supporting staff and reducing fatigue at night Develop the role of Clinical Practitioner and Advanced Nursing Practice at night Identify key strategies to change practice and ways of working in Hospital at Night Understand how hospitals can improve conditions for night workers and support Junior Doctors Improve the management of pain at night Work across whole systems to improve support for patients out of hours Self assess and reflect on your own practice Gain CPD accreditation points contributing to professional development and revalidation Evidence Register There are a limited number of free places for hub members. Email: info@pslhuborg if interested. Follow on Twitter @HCUK_Clare #hospitalatnight