Date of Completion
Summer 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Jill Schramm
Second Advisor
Dr. Brewer
Abstract
Problem: Inpatient falls were a significant safety issue at the project site, substantially affecting patient outcomes and organizational resources. The identified gap was the lack of individualized, patient-centered fall-prevention strategies despite the presence of standard fall-prevention bundles. The baseline fall rate of 6.04 was 20% higher than the national benchmark of three to five falls per 1,000 patient days, indicating a clear need for improvement.
Aim of the Project: The quality improvement (QI) project aimed to improve patient safety by reducing inpatient falls through implementation of the AHRQ Fall Tailoring Interventions for Patient Safety (TIPS) protocol on a 24-bed medical-surgical unit.
Review of the Evidence: Evidence supports multifactorial, nurse‑led, patient‑centered strategies such as the Fall TIPS interventions as effective for reducing inpatient falls, particularly when structured risk assessment, tailored interventions, and patient/family engagement are combined into a standard intervention.
Project Design: The project used a QI design guided by Plan-Do-Study-Act cycles and the OhioHealth Change Management Model to structure stakeholder engagement, staff education, and iterative workflow refinement during implementation.
Intervention: The intervention included staff education on the Fall TIPS protocol, routine use of standardized fall‑risk assessments, development of patient‑specific fall-prevention care plans, ongoing audit and feedback, and post‑fall debriefings to identify contributing factors and inform targeted education for staff, patients, and families.
Significant Findings/Outcomes: During the 12‑week implementation period, three patient falls occurred, yielding a post‑intervention fall rate of 3.3 falls per 1,000 patient days, a 45% reduction from baseline and within national benchmarks. Process audits identified initial reliance on generic care plans; after refresher training, the unit achieved 100% compliance with documenting individualized fall‑prevention plans and education. Estimated fall‑related costs decreased from $93,716 pre‑implementation to $20,082 during the project period, reflecting savings of approximately $73,634 (78.6%).
Implications for Nursing: The QI project demonstrated that the Fall TIPS protocol can reduce falls, strengthen safety culture, and generate substantial cost savings for patients and the organization. Findings support sustaining protocol within routine workflows with continued emphasis on structured processes, timely debriefings, targeted education, and leadership support to maintain gains and advance high‑value, safe care.
Recommended Citation
Adhikari, Yashu, "Tailoring Interventions for Patient Safety Protocol: A Strategy to Prevent Inpatient Falls" (2026). Doctor of Nursing Practice (DNP) Scholarly Project. 57.
https://fuse.franklin.edu/dnp-project/57
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