• Led by Adam Darowski, Consultant Geriatrician, John Radcliffe Hospital.
  • Run by the National Falls and Bone Health Programme in a variety of hospital settings across the South Central region of England.
  • Aimed to ensure that simple guidelines are implemented in hospital wards to reduce the incidence of patient falls.
  • Developed a resource pack about falls prevention.

Accidental falls are the most commonly reported patient safety incidents in NHS hospitals. The FallSafe project sought to ensure that simple guidelines are implemented in hospital wards to reduce the incidence of falls.

It did this by implementing evidence-based multifactorial falls prevention, delivered as care bundles, in a variety of hospital settings. The project team developed a resource pack about falls prevention, including the FallSafe care bundle and an e-learning course CD.

Key findings

  • The care bundle approach was highly effective at delivering improvements in processes of care.
  • There were marked improvements in some interventions with more than twice as many patients receiving assessments to identify causes of falls.
  • Staff nurses and junior sister/charge nurses can lead quality improvement projects and succeed in changing the behaviour of their peers.
  • The care bundles were feasible and acceptable across a wide range of inpatient settings.


  • Staff turnover – FallSafe leads developed their self-confidence and leadership skills and were sometimes promoted, leaving the project.
  • Need for staff to perceive falls prevention as a shared responsibility.
  • Finding time to implement and measure QI among competing priorities.
  • Delivery of QI training at an appropriate level.
  • Demystifying the process to gain staff engagement.

Who was involved?

The project was run by the National Falls and Bone Health Programme and led by Adam Darowski, Consultant Geriatrician, John Radcliffe Hospital, Oxford. The team included a range of professionals working with patients with falls.

The project was supported by partner organisations: the Royal College of Nursing, the National Patient Safety Agency, NHS South Central, the British Geriatrics Society, and the patient safety charity Action Against Medical Accidents.

Further reading

Learning report

Using clinical communities to improve quality

December 2013
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Closing the Gap through Clinical Communities


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