Multifactorial interventions to reduce inpatient falls on ward J11

Abstract

Background Ward J11 experienced a rise in inpatient falls following an increase in the frailty and acuity of patients on the ward, contributing to high monthly fall numbers. Despite enhanced care, wellbeing initiatives, audits and safety huddles, incidents did not reduce, highlighting the need for a multifactorial approach addressing medication risk and cross-disciplinary collaboration.

Aim To reduce inpatient falls and improve patient safety on J11 through a collaborative, medication-focused quality improvement intervention involving nursing, pharmacy and medical teams.

Methods The use of Leeds Improvement Method (LIM) guided PDSA cycles for this test of change, starting with Genba’s to understand the problem, utilising available data sets to assess the KPI baseline and instigate nursing-led tests of change which progressed to collaborating with pharmacy to develop standard work for inpatient medication reviews. The new process included routine medication reviews for admissions of patients of whom were an increased risk of falls, leading to the creation of standard work to ensure consistent MDT review processes. Proactive identification of medications contributing to inpatient falls created a robust mistake proofing concept improving from end of line to successive checks. This contributed to timely communication of potential harm via safety huddles and MDT meetings and empowered staff to be involved in individual patients' care prior to a fall happening.

Results Medication reviews led to a reduction in falls from six incidents per month to one within the first month (J11 Datix Incidents 2025), with improvements sustained for three consecutive months. Additional benefits included improved MDT collaboration, earlier identification of high-risk patients, reduced reliance on enhanced care, increased staff autonomy, and morale across the team.

Conclusion A multifactorial, pharmacy-integrated intervention significantly reduced inpatient falls and strengthened safety culture on J11. The approach is scalable and supports NHS priorities around patient safety, workforce wellbeing, and efficient resource utilisation.