Falls Reduction Through Safer Medicines Practice in Older People’s Services

Falls prevention in older people’s services is not just “more exercises” and “remove trip hazards”. A large proportion of avoidable falls are driven by medicines effects (sedation, postural hypotension, dizziness), inconsistent administration practice, and missed early-warning signs of deteriorating frailty. This article sets out a practical, auditable approach to medicines-led falls reduction, including how to evidence safer practice for commissioners and inspectors. It also links to the wider Knowledge Hub index and the relevant topic area: Knowledge Hub index and Medicines, Frailty, Falls & Safety.

Start with a clear risk picture: what “medicines-led falls risk” looks like

Older people frequently live with polypharmacy, fluctuating hydration, variable nutrition, pain, poor sleep, and frailty-related changes in balance and strength. These factors interact with medicines and create predictable patterns of falls risk. A practical service approach is to define medicines-led falls risk as any situation where medication timing, dose, side effects, interactions, or administration variability could reasonably contribute to instability or loss of consciousness.

Common contributory medicines and situations include:

  • New starts or dose increases of sedatives, opioids, antipsychotics, antidepressants, gabapentinoids, antihistamines, and some antiemetics.
  • Antihypertensives and diuretics contributing to postural hypotension, dehydration, or nocturia (increasing night-time falls).
  • Hypoglycaemia risk from diabetes medicines when appetite fluctuates.
  • PRN use that “creeps” into routine dosing without review (e.g., PRN hypnotics or anxiolytics).
  • Pain, constipation, urinary symptoms, and infection driving distress and agitation, then sedative PRNs being used as a quick fix.

Design safer medicines rounds: consistency, timing, observation, documentation

Medicines rounds are a high-risk operational process: distractions, time pressure, and variable technique can undermine safety. A falls-focused medicines round is designed to do more than “give tablets”; it systematically checks for side effects, hydration status, and functional changes, and it triggers escalation when risk increases.

Round standards that reduce falls risk

  • Protected rounds: no non-urgent interruptions; clear “do not disturb” approach with escalation rules for genuine emergencies.
  • Timing consistency: minimise variation in administration times for medicines linked to dizziness or sedation; plan staffing so night sedation and morning antihypertensives are not rushed.
  • Observation prompts: built into MAR practice: “drowsy?”, “unsteady?”, “new confusion?”, “postural symptoms?” recorded as brief structured notes where relevant.
  • Hydration check: for people on diuretics, laxatives, or with recent illness—include a quick prompt for fluid intake and signs of dehydration.
  • Mobility safety: anticipate toileting support after diuretics and evening sedatives; plan call bell response expectations around these predictable risk windows.

PRN governance: keep PRN “as needed”, not “as routine”

PRN medicines can be clinically appropriate and humane, but they are a common driver of falls when governance is weak. The key is to ensure PRN is used within a clear clinical rationale, with documented evaluation of effect and side effects, and a review cycle that prevents drift into habitual use.

Core PRN controls

  • Written PRN protocols: indication, maximum dose/24h, minimum interval, contraindications, and when to seek clinical advice.
  • Non-pharmacological first-line: clearly stated alternatives (repositioning, reassurance, toileting, fluids, pain assessment, sensory supports), so PRN is not the default response.
  • Effectiveness recording: document the observed outcome within a defined time window (e.g., 30–60 minutes) and note sedation/unsteadiness.
  • Trigger reviews: e.g., PRN used >3 times in 7 days, or any PRN associated with drowsiness, near fall, or fall—automatic GP/pharmacist review request.

Frailty-aware medicines review: build a routine that actually happens

Falls reduction is strengthened when medicines reviews are planned, scheduled, and actioned—not left to ad hoc requests. A robust approach uses multiple “review triggers” so the system catches risk early.

Practical review triggers

  • Any fall, near-fall, or unexplained bruise.
  • New confusion, daytime sleepiness, or change in gait.
  • Recent hospital discharge or medication changes.
  • PRN threshold breaches (as above).
  • Recurring night-time toileting, dizziness, or low blood pressure readings (where monitored).

To make reviews happen operationally, services often appoint a “medicines safety lead” (not necessarily a nurse) who tracks review triggers, chases responses, and ensures changes are implemented safely with staff briefings and updated care plan guidance.

Operational example 1: Sedation-related falls after a medication change

Context: A resident in a care home becomes unsettled at night. A sedating medicine is introduced. Within 72 hours they experience morning drowsiness and a near fall when walking to the bathroom.

Support approach: The service applies a “medicines change watch” protocol: increased observation for 7 days after sedating medicine changes, morning mobility support, and hydration prompts. Staff record sedation score (simple: alert / drowsy / very drowsy) during morning checks and medicines round notes.

Day-to-day delivery detail: Night staff proactively offer toileting support at predictable times. Morning staff do not encourage independent transfers until the person is fully alert. The MAR includes a brief note for “drowsy/unsteady” so patterns are visible. The manager triggers a pharmacist/GP review using a standard template: medicine change date, observed sedation, near-fall, and options considered.

How effectiveness is evidenced: The near-fall is logged, the review request is recorded, and the subsequent dose adjustment is captured in a change log. Falls/near-falls are tracked weekly. A short audit shows improved documentation of side effects and a reduction in morning unsteadiness incidents.

Operational example 2: PRN hypnotic creep and night-time falls

Context: PRN sleep medication is being given most nights to “help settle”. Night-time falls increase, with one unwitnessed fall at 03:00.

Support approach: The service introduces a PRN threshold rule and a bedtime routine pathway: pain check, toileting, hot drink, reassurance, noise/light controls, and only then PRN if criteria are met. Staff must record effect and any sedation or gait change.

Day-to-day delivery detail: The team leader reviews PRN usage daily for 2 weeks, flags any use beyond threshold, and calls a clinical review. Staff are briefed at handover with clear “do not use PRN as routine” language and practical alternatives. The care plan is updated to include a falls-safe night routine and call bell response expectations.

How effectiveness is evidenced: PRN administration reduces, night-time falls reduce, and documentation shows clearer rationales and outcomes. The service presents a PRN audit showing compliance with protocol and review triggers, which supports assurance to commissioners and inspectors.

Operational example 3: Postural hypotension risk and morning falls

Context: A person has repeated morning “wobbles” and one fall when standing from bed. They take antihypertensives and a diuretic. Appetite is variable.

Support approach: The service applies a “high-risk mornings” plan: slow positional changes, seated pause before standing, supervised transfers in the morning, hydration prompts, and GP review request focused on timing/dose and dehydration risk.

Day-to-day delivery detail: Staff use a simple script: “sit on the edge of the bed for one minute, then stand with support.” Toileting is supported to reduce rushing. If symptoms occur, staff document them consistently and escalate via a defined pathway. The medicines round includes a prompt to ask about dizziness and to record it.

How effectiveness is evidenced: The service tracks dizziness episodes and falls. The GP adjusts timing/dose, and the service documents the rationale, implementation, and outcome. A monthly falls meeting reviews whether the change improved stability and whether the plan is being followed.

Governance and assurance: make medicines-led falls prevention inspectable

Strong practice is only defensible if it is consistent, recorded, and reviewed. The most effective governance model links medicines safety, falls management, and clinical escalation into one joined-up assurance cycle.

Governance mechanisms that stand up to scrutiny

  • Falls & near-falls review: weekly review with action tracking (including medication triggers).
  • Medicines audits: MAR completeness, PRN documentation, controlled drug checks, and side-effect recording sampling.
  • Learning loop: “what changed after the fall?” documented—care plan updates, environment, staffing approach, medicines review requested/completed.
  • Competency checks: regular observed medicines rounds and PRN decision-making scenarios, with feedback and retraining.
  • Clinical escalation pathway: clear thresholds for contacting GP/pharmacy/111/999 and for post-fall monitoring.

Explicit expectations

Commissioner expectation: The service can evidence a proactive, systematic approach to falls prevention that includes medication risk management, timely reviews after incidents, and measurable improvement through audit and trend analysis (not just incident reporting).

Regulator / Inspector expectation (e.g. CQC): Medicines are managed safely with clear PRN governance, staff competency, accurate records, and learning from incidents. Inspectors can trace a fall event through documentation to see assessment, escalation, review, and sustained changes in practice.

What “good” looks like in day-to-day delivery

In a well-run service, staff can explain why a person is at risk, what they do differently on high-risk mornings or nights, how PRN decisions are made, and what happens automatically after a fall. Records show consistent observation of side effects, clear escalation actions, and visible review outcomes. This is how medicines practice becomes a tangible driver of reduced falls, rather than an isolated compliance function.

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Written by Impact Guru, editorial oversight by Mike Harrison, Founder of Impact Guru Ltd — bringing extensive experience in health and social care tenders, commissioning and strategy.

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