Document Type


Publication Date

Spring 2022

Date of Final Presentation


Committee Chair

Dr. Teresa Serratt

Committee Member

Dr. Pam Strohfus

Coordinator/ Chair of DNP Program

Dr. Pam Gehrke

Abstract/ Executive Summary

Background: Falling in the hospital setting is a leading cause of death and disability for patients. For many health care organizations, patient fall prevention strategies have become a priority focus to improve patient outcomes and associated costs.

Project Design: The project was designed to implement a quality improvement project on an adult medical/surgical unit, providing educational activities to nursing staff, and applying a standardized fall prevention plan of care “toolkit” for fall prevention interventions.

Results: Audits completed on 863 patient admits to a 36-bed Medical/Surgical unit during the three-month timeframe, showed the implementation of the project resulted in the creation of a personalized fall prevention plan for 96% of the patients admitted. Unintentional patient falls for the unit decreased from 5.26 falls per 1000 patient days the previous year to 1.78 patient falls per 1000 patient days during the three months the project was implemented. Patient knowledge audits showed 94% of patients were able to identify at least one of their fall risk factors and 93% were able to verbalize a fall prevention intervention.

Recommendations: The results of the pilot study indicate the project should be implemented on other units to help decrease patient falls hospital wide. Ensuring hospital and clinical leadership are engaged in the project is crucial to the success of translating evidence-based care into clinical practice. A patient-care team partnership appears to be beneficial for prevention of falls and fall-related injuries.

Conclusions: The implementation of a standardized fall prevention program decreased patient falls in the medical/surgical setting over a three-month period. On-going monitoring is needed to continue to evaluate the effectiveness of the program.

Included in

Nursing Commons