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Document Type

DNP - University Access Only

Award Date


Degree Name

Doctor of Nursing Practice (DNP)


Graduate Nursing

First Advisor

Linda Herrick


Falls are a leading cause of injury in hospitalized patients and are often preventable. A vast amount of evidence exists indicating fall prevention practices need to include multicomponent interventions based on current evidence. However, a specific bundle of interventions to decrease fall rates are yet to be identified. This PIP proposed a fall prevention toolkit based on current evidence and key stakeholder insight to decrease the fall rates in an acute hospital setting. Project development was guided by the Johns Hopkins Nursing Evidence-Based Practice Model, Rogers’ Diffusion of Innovation Theory, and the Plan-Do-Study-Act Model. All patients, regardless of risk, received a standard set of fall prevention efforts, including hourly rounding. However, those patients assessed to be at high risk of falling, based on fall risk assessment score, had a fall prevention toolkit implemented. The toolkit included patient and staff education, communication of risk factors with visual identifiers (signage on door, red nonskid footwear), physical therapy consult with physician order, pharmacy notification to review medications pre and post fall, and a post fall safety huddle. Data on fall rates, adherence to the toolkit, and nursing staff satisfaction were collected and analyzed. Data were collected in March, April, and May 2014 and compared to data from the same months in 2013. There were 483 patients assessed to be at a high risk of falling during the intervention period. The mean age was 66 years old and the sample was composed of 50% males and 50% females. The mean fall risk assessment pre fall was 2.79 and 3.5 post fall. Of the 14 falls that occurred during the intervention period 57.14% were anticipated, 14.29% were unanticipated, and 28.57% were accidental. The high rate of accidental falls may have contributed to the low pre fall risk assessment score, but the ability of the assessment tool to accurately predict high fall risk should also be considered along with staff’s ability to correctly use the tool. The fall rate or fall severity did not significantly decrease (p = .20; p = .56) when comparing 2014 to 2013 data, but the difference between mean fall rates was 2.32, suggesting clinical significance. Staff adherence / compliance with implementation of the FPTK was calculated and analyzed using percentages and means. The entire toolkit was implemented 62% of the time, with adherence levels being higher for certain interventions and lower for others. A staff satisfaction survey was completed by staff voluntarily post implementation. The response rate was 48%. Staff reported being significantly likely to support the FPTK in the future and felt it significantly improved patient safety on the nursing unit. Despite the lack of statistical significance, there is still value in the clinical significance found from this project. This project provided a framework for the organization to base further recommendations and studies. More research is needed to determine the most effective interventions and staff adherence strategies in fall prevention programs.

Library of Congress Subject Headings

Falls (Accidents) -- Prevention
Hospital patients -- Care


Includes bibliographical references (pages 78-83)



Number of Pages



South Dakota State University


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