Antidepressants have long been recognized as a contributory factor to falls and many studies show an association between antidepressants and falls. There are extensive data for tricyclic antidepressants (TCAs) and related drugs, and for selective serotonin reuptake inhibitors (SSRIs), but few data for other classes of antidepressants. Sedation, insomnia and impaired sleep, nocturia, impaired postural reflexes and increased reaction times, orthostatic hypotension, cardiac rhythm and conduction disorders, and movement disorders have all been postulated as contributing factors to falls in patients taking antidepressants. Sleep disturbance is a cardinal feature of depression, and all antidepressants have effects on sleep. TCAs and related drugs cause marked sedation with daytime drowsiness. SSRIs and related drugs have an alerting effect, impairing sleep duration and quality and causing insomnia, which may result in nocturia and daytime drowsiness. Daytime drowsiness is a significant risk factor for falls, both in untreated depression and in depression treated with antidepressants. Clinically significant orthostatic hypotension is common with TCAs and related drugs, the older monoamine oxidase inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRIs). It occurs less commonly with SSRIs, and rarely with moclobemide and bupropion, and is not reported as a significant adverse effect of hypericum (St John's wort). Cardiac rhythm and conduction disturbances are well recognized with TCAs, tetracyclics and SNRIs, but have also been reported with SSRIs. The contribution of antidepressant-induced conduction and rhythm disturbances to falls cannot be assessed with current data. There are insufficient data to exonerate any individual antidepressant or class of antidepressants as a potential cause of falls. The magnitude of the increased risk of falling with an antidepressant is about the same as the excess risk found in patients with untreated depression.

: introducing evidence-based care bundles of multifactorial assessment and intervention using a quality improvement approach resulted in improved delivery of multifactorial assessment and intervention and significant reductions in fall rates, but not in injurious fall rates.

We studied 74 patients whose temperature was normal according to nurses' temperature charts and who were not on antibiotic treatment. The subjects were inpatients whose condition had deteriorated on the ward, or patients admitted the previous day in whom no diagnosis had been established. One simultaneous set of measurements was made of sublingual, rectal, axillary and proximal auditory canal temperatures. A fever was recorded in 63 of 74 patients (85%); 54 febrile patients had a raised rectal temperature, and 54 had a raised proximal auditory canal temperature; 60 patients were febrile at one or both of these sites. A further three patients had raised sublingual temperatures alone. All patients who were regarded as being definitely or probably infected were febrile at one or more sites. Eighty-one per cent of those considered to be possibly infected, and 71% of those with no clinical evidence of infection were also febrile. Rectal and proximal auditory canal temperatures can each detect fever in approximately 86% of febrile patients, sublingual temperature in 66%, and axillary temperature in 32%. Rectal temperature is clinically the most useful temperature measurement in elderly patients. We conclude that significant infections in patients in a warm environment result in a fever which often remains undetected when only sublingual temperature is measured.

Fifty hospital inpatients were selected, who, on the basis of their history and on clinical and laboratory findings, were believed not to have a febrile illness. Body temperature was measured simultaneously at four sites, in order to compile a normal range of temperature at each site for patients under these conditions. The observed range of rectal temperature was 36.7-37.5 degrees C, auditory canal temperature 36.4-37.2 degrees C, sublingual temperature 36.2-37.0 degrees C, and axillary temperature 35.5-37.0 degrees C.

Over a quarter of a million falls are reported by the UK hospitals each year, predominantly harming older patients whose vulnerability to falling arises from a complex interaction of risk factors, including impaired mobility, dementia, delirium, medication and the effects of long term and acute illness. Systematic review of research trials indicates that multifactorial assessment and intervention to treat, modify or better manage these underlying risk factors can reduce falls by 20 -30%. However, the evidence base is not always reflected in hospitals' falls prevention policies, and is not consistently delivered to patients. The organizational culture and processes that can increase the effective delivery of evidence-based falls prevention are discussed, alongside learning from quality improvement projects. Systematic learning from reported falls and essential care after an inpatient fall are also explored.The scale of the challenge Falls are defined as "an unexpected event in which the participant comes to rest on the ground, floor, or lower level" 1 -a definition that in the hospital setting encompasses slips, trip, faints, collapses and patients who are found on the floor. 2 Falls are the most commonly reported patient safety incident in almost all acute and community hospitals and mental health units, with over 280 000 falls reported in England and Wales each year 3 and over a thousand falls per year reported from an acute hospital of average size. 2 Falls predominantly affect and harm older, frailer people; over 80% of falls in hospital occur in patients aged over 65 years, with the highest falls rates and the greatest vulnerability to injury seen in patients aged over 85 years. 2 Falls can have serious consequences; 30% of falls in hospitals result in some injury, and almost 2000 fractures are reported annually. 3 People who are hospital patients when they fall and fracture have poor outcomes and greatly extended lengths of stay and for some, the "final straw" of a serious injury on top of their pre-existing long term and acute illnesses will prove fatal. 4 Inquests into the deaths of patients who have fallen in hospital frequently indicate a catalogue of missed opportunities to prevent the fall (Box 1).Not all falls have such serious consequences, but even falls with minor or no injury can cause anxiety and distress to patients and their families, and create a downward spiral where the fear of falling leads to reduced mobility, increased dependency and an extended length of stay, or triggers a move to a care home. 4 Although successful litigation cases related to hospital falls are relatively rare (less than 30 per year in England) and the financial settlements are usually low (averaging around £13 000), 5 the considerable potential for harm to patients and to the hospital's reputation make the prevention of falls an important patient safety challenge for clinical and managerial staff.