• Key Contacts

    For further information on this project, please contact the following staff who were previously part of the West Metro Vaccination Program:

    • Fay Walsh
    • Dr Ruwani Mendis
    • Dr Maria Coperchini
  • Acknowledgements

    Dr Nisha Nadarajan

    Lisa Shaw (RN) Falls Champion Lead

Video Abstract

Click on the following image to view a short video abstract of this project.


Falls among patients admitted to a Palliative Care Unit contribute to significant morbidity and reduced quality of life. The high incidence of falls on the Sunshine Palliative Care Unit (PCU) prompted an internal falls audit with the objectives to describe the incidence and  characteristics of falls in this patient group, identify possible risk factors and review the satisfactory completion of fall documentation. These results informed the adoption of successful strategies to reduce the incidence of falls.

Issue for Improvement

Inpatient falls on the Sunshine Palliative Care Unit


All falls between February 2020 and February 2021 were identified using RISKMAN. Data relating to patient characteristics, falls risk factors and falls incidence were retrospectively obtained from a combination of electronic medical records and mandatory incident reports. Each incident report was independently reviewed by two investigators to determine completeness, appropriateness, and quality of report content.


There were a total of 115 falls involving 69 patients, with twenty patients (29%) having more than one fall. Clinical features of patients who had at least one fall included a diagnosis of metastatic cancer, administration of opioids (88%), prior to the fall, needing assistance with ambulation, and bowel or bladder incontinence.  Most falls were unwitnessed (90%) occurring in the patient’s room (82%) with equal distribution between nursing shifts. Patients sustained an injury in 36 % of the falls. On the day of the fall, most patients were either in the deteriorating (57%) or terminal (21%) palliative care phase. Only 34 % of falls were reported adequately.


The SPCU has initiated a “Falls Champion review process” led by senior nursing staff. A specially designed script for documentation is triggered at admission, following a fall or upon a change in a patient’s condition. The Falls Champion team highlights the issue of falls on the ward and engages patients and families in developing highly personalised fall prevention plans.  Consequently, SPCU experienced 55 days with zero falls. This multidisciplinary initiative improves patient outcomes whilst being cost neutral sustainable and is closely aligned with the values of Western Health.