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P-145 Rising up – falls improvement
  1. Deborah Pegram,
  2. Tom Osborne and
  3. Jane Naismith
  1. St Joseph’s Hospice, London, UK


Background We were aware from reviewing incidents that we had a high number of falls and repeat falls in 2017. We had 107 falls from 64 patients. Clearly, we aim to have a harm-free environment but also want to maintain patients’ independence. We have therefore embarked on an improvement journey to significantly reduce falls whilst maintaining a patient-enablement approach.


  • Reduction in number of falls on the inpatient unit with no restriction on patient enablement and independence;

  • Developing a learning culture around falls;

  • Increased staff knowledge around their role in preventing falls;

  • Education for patients and their families.

Methods We created a multidisciplinary falls group where everyone’s ideas and contribution is respected. This group:

  • Reviewed assessment process to reflect NICE guidelines;

  • Reviewed equipment;

  • Monitored trends;

  • Developed and implemented a ‘Safe use of bed rails’ policy;

  • Developed and implemented 1:1 observation policy;

  • Falls Information leaflet produced for patients and relatives;

  • Creation of Post Falls Protocol;

  • Ran falls prevention and awareness days which included training;

  • Reviewed each patient’s outcome measure of performance (AKPS) and phase of illness.

Results Applying an all falls matter approach, with the combination of comprehensive guidelines, staff education (including Dementia/Namaste training) the purchase of new alarmed low beds, and patient and family education, we have been able to halve the number of falls in 2018 and dramatically reduce the number of repeat falls. The majority of falls occur in patients with an AKPS of 50% and have a deteriorating phase of illness.

Conclusions Our approach has demonstrated a significant reduction in the number of falls without impacting on patients’ independence. Quality of life and increased confidence in patients and staff is marked. We have seen a culture change within our team, where all falls and near miss falls are treated with the same importance.

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