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Posted on 15 Feb 2021
Patient experience and outcomes

This case study was taken from our Sentinel events report 2019-20.

Beechworth Health Service (BHS), like many other health services across Victoria, experienced patient falls as one of their most frequently occurring preventable patient safety incidents. This led to falls prevention in residential aged care and throughout the hospital becoming one of their major priority areas for strategic improvement.

BHS has taken a creative and innovative approach to achieve falls prevention from multiple angles. A deep-dive of 10 years of falls data provided important information – like when were falls occurring, who the at-risk patients were and identified the common denominators across falls incidents.

Creating a novel partnership with Life Saving Victoria to reduce patient falls

One of the key insights from the data analysis by BHS was that most falls occur when people are alone (over 70 per cent). BHS reached out to Life Saving Victoria (LSV) which identifies similar risks in their working environments – people get into trouble in the water when they are alone. BHS used the ‘outsider’ perspective of LSV to introduce effective falls prevention strategies such as a ‘gaze refresh’ for staff, scanning for hazards and minimising time spent alone for at-risk patients. These were introduced in combination with related initiatives, some of which included:

  • training and education for staff on the new approach and opportunity to be involved
  • purchasing additional falls monitoring equipment including a new alert system to contact staff quickly
  • technology improvements enabling clinicians to view and document patient information at their bedside rather than leaving the room to access a computer
  • mobility improvement for elderly residents including intergenerational activities with local young school students (paused due to the coronavirus (COVID-19) pandemic)
  • safety huddles implemented for every shift in every unit. All staff – including service and catering staff –participate in the huddle to discuss emerging safety issues. Involving non-clinical staff has been instrumental in identifying hazards that may have otherwise been overlooked, as well as reinforcing that safety is everyone’s responsibility.


BHS also considered falls awareness in the wider community and introduced a Health Heroes program (based on LSV Nippers principles) as a school holiday activity. This included falls risk and awareness for intergenerational family and friends.

Celebrating ‘falls-free’

BHS sends daily email updates to all staff acknowledging achievements and ‘falls-free’ intervals, such as a falls-free shift, day, week or month. This focus on achievement and celebrating when things are going right is a simple yet effective recognition of staff efforts and encourages people to sustain their good work.

Achieving positive outcomes

BHS observed a significant reduction in falls as prevention strategies were implemented. In 2019–20 there was a 30 per cent reduction in the number of falls compared to the previous financial year, and the lowest it had been in 10 years. Overall fall severity has reduced to mostly minor or no harm.

Numerous benefits can be drawn from this, most importantly less harm and increased wellbeing for patients and their families. As the low falls environment continues, there is an increased awareness and commitment by all staff to actively prevent falls.

Incident reporting has also increased, including in areas outside of patient falls, demonstrating the positive impact on safety culture, transparency and reporting throughout the health service. BHS will continue to expose its thinking and its practice to improvement and is committed to a safety culture that best represents what matters to its residents, patients and clients.

Page last updated: 15 Feb 2021