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Content ArticleThis is the recording of a webinar which took place on the 30 April 2026, hosted by the State Claims Agency, focused on clinical risk, state indemnity, and learning from claims and incidents involving slips, trips and falls. Delivered by the Agency's Clinical Risk Unit, this webinar provided an updates on the unit’s work and share clinical risk snapshots, answered common questions about the Clinical Indemnity Scheme and shared learning from slips, trips and falls incidents and claims. The State Claims Agency is the name given to the National Treasury Management Agency in managing personal injury and third-party property damage claims against the State and State authorities, as delegated by Government, in the Republic of Ireland.
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Content ArticleAcross hospitals in Northumberland and North Tyneside, decaf (decaffeinated) drinks are not routinely offered to patients during drinks rounds. However, a wide range of specialists agreed that there could be different benefits to making decaf drinks the norm. A key one is a potential reduction in patients falling as they try to go to the toilet. Therefore, they ran a pilot in May 2024 to discover the impact on reduced falls, and patient and staff experience. The initial findings were very positive. They have now expanded the project to collect more feedback. Read more about what they did and download their poster.
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Content ArticleA repository of resources aimed at patients and carers which have been co-produced by the Falls and Fragility Fracture Audit Programme (FFFAP) patient and carer panel. The resources below have been categorised into the three audits within FFFAP: National Hip Fracture Database (NHFD) National Audit of Inpatient Falls (NAIF) Fracture Liaison Service Database (FLS-DB) Hip fracture: a guide for families and carers All about your hip fracture and what to expect on the road to recovery Recovering after a hip fracture: helping people understand physiotherapy in the NHS How should your hospital prevent and respond falls during your stay Inpatient falls Falls prevention in hospital: a guide for parents, their families and carers What should happen if you or someone you know experiences a fragility fracture Six golden rules for stronger bones Strong bones after 50 - after staying on treatment
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News ArticleElderly people who suffer falls are having to wait up to six hours for an ambulance because of rising Covid pressures, a medical body has warned. The delays are due to paramedics having to prioritise 999 calls from people suffering from coronavirus related breathing difficulties. Read full story (paywalled) Source: The Telegraph, 1 January 2021
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News Article
Falls team on the up thanks to North Wales volunteers
Clive Flashman posted a news article in News
A dedicated team of 32 volunteers are hitting the roads across North Wales assisting the Welsh Ambulance Service in dealing with fallers. Based out of the Ambulance headquarters in St Asaph, the Community First Responder Falls Team was launched on 30 April this year and has already assisted almost 250 people. The team was created to use the talents and experience of the familiar Community First Responders (CFRs) who had to be stood down from their normal duties at the start of the Covid-19 pandemic. Read the full article here. -
Content Article
NHS Resolution: Manual handling (19 October 2020)
Patient Safety Learning posted an article in Patient management
From 1 April 2009 to 31 March 2019, NHS Resolution was notifed of 4,733 claims relating to manual handling. NHS Resolution has produced a 'Did you know' guide on manual handling. -
News ArticleA Surrey hospital trust has become the first in the country to appoint a nurse dedicated to preventing patient falls and medication mix-ups. The consultant nurse has been appointed by Ashford and St Peter's (ASP) Hospital NHS Foundation Trust to reduce the number of patients who are injured while being treated at its sites. This includes looking at ways to reduce the amount of people who fall over, suffer with venous thromboembolism or experience tissue damage while in hospitals in north west Surrey. The trust says the harms prevention nurse will be the first in the country hired for such a role and will also work with the team who look at incidents of medication mix-ups and mistakes. Read full story Source: Surrey Live, 4 February 2020
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Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar to address a central patient safety topic aligned with our Actionable Patient Safety Solutions (APSS). Tune in here for a deep dive on APSS #14, Falls and Fall Prevention.
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Content ArticleDespite increasing recognition of the potential risks associated with in-hospital newborn falls among health professionals, new parents are frequently unaware of the possibility of dropping their newborn, especially in the hospital. Although most newborn falls do not result in lasting harm to the newborn, they may need additional healthcare services and cause stress to the parents. The report suggests strategies to prevent newborn falls in the hospital, whichl include: focusing efforts on providing support for exhausted parents during the critical time following the birth offering periods of rest for new parents whenever they are tired increasing the frequency of rounding when new mothers are breastfeeding promoting a midday break in visiting hours. In cases where a newborn fall event does occur, facilities should provide support to both injured newborns and any caregivers involved. In many cases, parents and other caregivers may benefit from counselling to help them better navigate the emotional turmoil that often follows these events.
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Content ArticleEast Kent Hospitals University NHS Foundation Trust is delighted to have been the recipients of the Patient Safety Learning Award 2019 for ‘Professionalising Patient Safety’ for our FallStop programme. FallStop is a quality improvement programme, developed in 2016, when we found there was a high number of falls at one of our hospitals and a failure to learn from serious incidents. The same site had performed poorly in the National Audit of Inpatient Falls in 2015 and we knew we needed to make a change. Our aim was to reduce the incidence of falls and harm and embed falls prevention into everyday practice, by engaging clinical staff to identify patients at risk and implement harm prevention strategies. We chose target wards, on a rolling programme, starting with areas with a high number of falls and those where serious falls had occurred. Integral to the success of FallStop is for wards to understand and own their data and culture. We discuss their fall incidents, rates and falls risk assessment audit results for the previous year. The focus is for each area to decide what they need and want to improve, which we do with their Falls Link Workers and Ward Manager. To support the programme we recruited, to work with the nursing team, a single FallStop Associate Practitioner, whose primary role is to deliver a comprehensive training session to clinical staff. This covers completion of our Falls Risk Assessment and Care Plan, use of harm prevention strategies and post fall care. Over 1,000 clinical staff have received the full training, but the FallStop Associate Practitioner also supports clinical induction sessions every 2 weeks for new clinical staff, by providing a falls awareness session. A thorough falls risk assessment and development of a comprehensive care plan is the most important part of preventing falls and this is emphasised during training. The programme has evolved and we have used innovative ways to improve all aspects, including keeping the data simple. Wards can self -audit their compliance with risk assessments and post fall care by using quick and simple electronic audits and have immediate results in colourful bar and pie charts. We also created a Falls Dashboard for overall Trust data, which is now being further developed to enable wards to drill down to their own data. Results One of the things we sometimes find is that staff do not think that falls is a problem in their area. By sharing their data, discussing serious incidents and talking about training they become much more self-aware and are able to set and own their own goals. In 2016-2017 (pre FallStop) the Trust fall rate was 5.79 per 1000 occupied bed days with the problem hospital rate at 5.55. 2017- 2018 (practitioner in post and programme being rolled out) the Trust rate was 5.34, problem hospital rate at 5.48. In 2018-2019 (FallStop implemented), Trust rate at 5.05, problem hospital rate at 5.13. The avoidable hip fracture incidents have halved from 8 in the previous year to 4 in this year. Next steps We are now helping wards to triangulate their own data. If they can see that staff have received FallStop training and that the number of falls and harms have decreased, they are able to recognise the value of the programme for their patients and team. We have listened to our staff and are developing the Trust’s Falls Steering Group. Whilst it will continue to be chaired by the Deputy Chief Nurse, a representative body of band 7 clinical staff (usually, but not restricted to, Ward Managers) will become members. These are all volunteers who are passionate about preventing falls. We hope that this will enable a cohesive ward to board approach where we can all understand the issues facing clinical staff, whilst keeping clinical staff aware of local and national expectations. It has already improved understanding and is breaking down the barriers. As a result we are planning events for staff to ‘drop in’ and discuss falls and present their own ideas. To celebrate staff achievements we are about to implement ’FallStop Friends.’ Our friends will be presented with certificates and appear in our Trust news and Twitter feed. When we developed FallStop we wanted a unique branding and came up with our own logo. It is widely known across the Trust and we have shared this concept with our peers at other hospital Trusts. We use it for all our communication tools, from reports to desktops, posters to risk assessments. Our next step is to choose what to do with our prize. We have decided to listen to our clinical staff at ‘drop ins’ and find out what they think makes a difference. We will then choose one or two of their ideas to help the Falls Prevention Team visit a hospital, team or service which is successfully addressing the chosen idea. We are committed to continue to develop FallStop locally and share our experience to support our peers in other Trusts with their own programmes.
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Content ArticleFallStop is a quality improvement programme from the Falls Prevention Team at the East Kent Hospitals University NHS Foundation Trust. It was developed in 2016 when they found there was a high rate of falls at one of their hospitals and a failure to learn from incidents. A FallStop Practitioner co-ordinates the programme and delivers training. Objective Reduce incidence of falls and harm. Embed falls prevention into everyday practice. Engage clinical staff to identify patients at risk and implement harm prevention strategies. Process for target wards: Present data for the past 12 months for falls by severity, as baseline metric. Present serious falls and actions undertaken. Falls Risk Assessment audit as baseline metric. Falls Link Worker ensures a display board is refreshed with falls prevention displays and audit result. Ward team set own targets for improvement weekly. Teaching sessions delivered. These may be ward sessions or in the Quality Improvement and Innovation (QII) hub. Weekly audits continue. Evaluation: Meeting with the team to discuss programme results, falls incidences, post fall assessment themes and audit results. Link worker provides evidence of training undertaken and plan for those who have not received training. Improvement plan agreed to be delivered by the link worker.
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Content Article
Clifton Hospital: Crafted falls wall
Claire Cox posted an article in Patient safety in health and care
This amazing crafted wall was made by staff from Ward 1 at Clifton Hospital, Blackpool Teaching Hospital NHS Foundation Trust. It explains what is required to prevent patient falling. -
Content ArticleFrimley Health NHS Foundation Trust have devised a patient leaflet to help patients play a role in their safety while at the hospital.
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Content ArticleThis paper published by Mangar Health gives an insight into the costs, personal and financial, of falls and how simple investment of equipment in the right place at the right time could potential save lives and significant money.
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Content ArticleThe risks of accidentally dropping a baby are well known, particularly when a parent falls asleep while holding a baby; or when a parent or healthcare worker holding the baby slips, trips or falls. However, despite healthcare staff routinely using a range of approaches to make handling of babies as safe as possible, and advising new parents on how to safely feed, carry and change their babies, on rare occasions babies are accidentally dropped. This safety alert was issued after a consultant neonatologist raised concerns about an increase in the number of accidentally dropped babies in his organisation. A search of the National Reporting and Learning System (NRLS) for a recent 12 month period identified; 182 babies who had been accidentally dropped in obstetric/ midwifery inpatient settings (eight with significant reported injuries, including fractured skulls and/or intracranial bleeds), 66 babies accidentally dropped on paediatric wards, and two in mother and baby units in mental health trusts. Almost all of these 250 incidents occurred when the baby was in the care of parents or visiting family members.
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Content Article
Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. The importance of fall prevention extends beyond patient safety—it reduces hospital liability, enhances patient outcomes and improves overall healthcare efficiency. By proactively assessing and addressing fall risks, healthcare providers can significantly lower the incidence of falls, ensuring a safer environment for patients. Given the aging population and increasing chronic disease burden, fall prevention remains a top priority in improving patient care and quality of life. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. Introduction Falls among patients, particularly in healthcare facilities, remain a pressing concern worldwide. These incidents not only lead to injuries, prolonged hospital stays and increased healthcare costs, but can also have lasting psychological impacts on patients. Preventing patient falls necessitates a multifaceted approach, with fall risk assessment at its core.[1] Understanding the impact of patient falls Patient falls are defined as unintentional descents to the ground that occur in healthcare facilities, including hospitals, nursing homes and rehabilitation centres. According to the World Health Organization (WHO), falls are the second leading cause of unintentional injury deaths globally, with older adults being most at risk.[2] In healthcare facilities, the consequences of falls extend beyond physical injuries; they also affect a patient’s confidence, independence, and quality of life. The financial burden of falls on healthcare systems is substantial. Costs include direct expenses such as treatment for fall-related injuries and indirect costs like litigation, reputation damage and loss of trust. Additionally, healthcare providers experience emotional distress and professional repercussions when preventable falls occur under their watch. Hence, fall prevention is not just a patient safety priority but also an ethical obligation and a cost-saving measure. The role of fall risk assessment Fall risk assessment is a systematic process to identify patients at risk of falling. Healthcare providers can implement targeted interventions to mitigate these risks by evaluating intrinsic and extrinsic factors. Intrinsic factors include age, medical history, mobility impairments and cognitive status, while extrinsic factors encompass environmental hazards, medication side effects and inadequate assistive devices. Risk assessment tools, such as the Morse Fall Scale, Hendrich II Fall Risk Model and STRATIFY Risk Assessment Tool have been widely used. These tools provide a structured approach to assess risk levels and guide preventative measures. However, their effectiveness depends on accurate application and regular updates based on patient conditions. Implementing effective fall risk assessments To maximise the efficacy of fall risk assessments, healthcare facilities must adopt evidence-based strategies and integrate them into their workflows. Key steps include: Standardised assessment protocols: Developing and adhering to standardised protocols ensures consistency in evaluating fall risks across different departments and shifts. Protocols should specify the frequency of assessments, criteria for reassessment and documentation requirements. Staff training: Comprehensive training programme for healthcare workers are essential to enhance their competency in conducting fall risk assessments. Training should cover assessment tools, recognition of risk factors and communication of findings to the care team. Patient and family education: Involving patients and their families in fall prevention efforts fosters a collaborative approach. Educating them about potential risks and preventive measures empowers them to contribute to safety. Technology integration: Advanced technologies such as wearable sensors, predictive analytics and electronic health records (EHRs) can augment traditional fall risk assessments. For instance, sensors can monitor patient movements and alert staff to potential falls, while EHRs can flag high-risk patients for closer observation. Challenges in implementing fall risk assessments Despite its benefits, implementing fall risk assessments is not without challenges. Common barriers include: Resource constraints: Limited staffing, time pressures and inadequate funding can hinder comprehensive risk assessments. Overburdened staff may struggle to prioritise fall prevention alongside other responsibilities. Inconsistent application: Variability in applying risk assessment tools can lead to inaccurate results. Subjective judgment, incomplete data collection and lack of protocol adherence contribute to inconsistencies. Resistance to change: Resistance from staff and administrators to adopt new practices or technologies can impede the integration of fall risk assessments into routine care. Patient non-compliance: Some patients may resist interventions such as bed alarms, mobility aids or supervision, increasing their risk of falling. Strategies to overcome the challenges To address these challenges, healthcare facilities can adopt the following strategies: Leadership support: Strong leadership commitment is crucial to allocating resources, establishing accountability and creating a safety culture. Interdisciplinary collaboration: Engaging multidisciplinary teams, including nurses, physicians, physical therapists and pharmacists, ensures a holistic approach to fall risk assessment and prevention. Continuous Quality Improvement: Regular audits, feedback sessions and performance evaluations help identify gaps in fall prevention efforts and drive improvements. Tailored interventions: Personalising interventions based on individual patient needs and preferences increases their acceptability and effectiveness. Conclusion Preventing patient falls requires a proactive and comprehensive approach, with fall risk assessment as a foundational element. Healthcare facilities can significantly reduce fall-related incidents and their associated consequences by identifying at-risk individuals and implementing tailored interventions. However, the success of fall prevention efforts hinges on overcoming implementation challenges through leadership support, interdisciplinary collaboration and continuous improvement. As healthcare systems evolve, leveraging technology and prioritising patient-centred care will be instrumental in advancing fall risk assessments. By embracing these advancements, healthcare providers can create safer environments that uphold all patients' dignity, independence, and well-being. References The Joint Commission. Fall Reduction Program - Definition and Resources, 28 August 2017 WHO. Falls Factsheet. World Health Organization, 26 April 2021. -
Content ArticleMedications and specifically fall-risk-increasing drugs (FRIDs) are associated with increased risk of falls: reducing their prescription may improve this risk. This study from Cox et al. explored patient characteristics associated with FRID use, prevalence and type of FRIDs and changes in their prescriptions among older people with arm fractures over 6 months. The study found that more than one FRID prescription had a significantly higher number of co-morbidities and medications and higher rates of male gender, polypharmacy, frailty and sarcopenia. The most frequently prescribed FRIDs were antihypertensives, opioids and antidepressants. Use of FRIDs among older people with upper limb fragility fractures was high. Although overall use decreased over time, 59% were still on 1 or more FRID at the 6-month follow-up, with trends to stop opioids and start antidepressants. Older people presenting with upper limb fractures should be offered a structured medication review to identify FRIDs for targeted deprescribing.
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Content ArticleImperial College Hospital NHS Trust have launched their new falls safety improvement video to highlight the importance of safe mobility in hospital. Watch the video and join the conversation on Twitter.
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Content ArticleFalls are the most common cause of preventable injury. Being hospitalized puts patients at further risk for falls due to illness and the newness of the hospital environment. Unfamiliar surroundings, medications and treatments given in the hospital setting, and decreased activity can cause patients to become mentally confused, weak, and unsteady. Even patients who were active and independent at home may require assistance to complete simple activities safely while they are in the hospital, such as getting out of bed or using the bathroom. This toolkit, developed through an AHRQ Patient Safety Learning Lab, consists of a formal risk assessment and tailored plan of care for each patient. The toolkit has reduced falls by 25% in acute care hospitals and is used in more than 100 hospitals in the United States and internationally. Further reading on the hub: Editing Top picks: Ten fall prevention resources
