This article describes a 10-year programme of work that has reduced inpatient falls rate by 46% and how this improvement has been sustained. The methodology applied in this initiative has forced one Trust to challenge expectations about the inevitability of patient falls in hospital. This initiative has resulted in approximately 568 fewer falls each year. Based on costings from NHS Improvement, the estimated 5108 fewer falls between 2011 and 2019 have saved the Trust £13.3 million.
Keywords: After action reviews; Complexity science; Patient falls; Patient safety; Reflective practice.