Date of Completion
Fall 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
Abstract
Problem: The Step-Down Unit (SDU) had a high fall rate of 4.8 falls/ 1,000 patient days, falling short of the 3.0 falls/1,000 patient days organizational target. Despite the high fall rate, the unit used a one-size-fits-all approach, which was ineffective. Also, nursing practices in the unit were unevenly adopted.
Project Objective: The project aimed to lower the fall rate in SDU by 10% and increase compliance with risk-stratified documentation to at least 90%.
Evidence Review: A huge pool of evidence supported the adoption of a multifactorial, person-centered fall prevention approach as opposed to universal precautions. The AHRQ Fall Prevention Toolkit provided a practical framework for matching patients to unique interventions based on their risk level.
Project Design: An iterative testing process was based on a quality improvement (QI) design based on the Plan-Do-Study-Act (PDSA) model. The OhioHealth Change Management Model (OHCM) promoted sustainability and staff involvement.
Intervention: The interdisciplinary team adopted a targeted risk-stratified falls prevention bundle integrated with the EHR that categorized patients based on their risk level. These categories were then linked to individualized safety interventions. For optimal outcomes, implementation of the intervention was guided by education, visual cues, audits, huddles, and peer coaching.
Findings/Outcomes: The intervention reduced falls in the SDU unit by 12.5% within the implementation period, as patient falls per 1,000 patient days reduced from 4.8 to 4.2. At the same time, injuries emanating from falls in the unit reduced by 25%, and compliance rose to 95% within the same period. Another notable finding was that injury-related expenses reduced by $1,000, from $4,000.
Implications to Nursing: The findings suggest that adopting a risk-stratified fall prevention approach provides a robust basis for nurses to render individualized, consistent care. Also, the reduced rate of falls in the unit shows the possible benefits of early identification of risks specific to each patient and addressing them promptly. In turn, this approach improves patient safety by ensuring fall prevention is integrated with routine care.
Action Items: To sustain this intervention, the prevention bundle must be integrated into unit policies, nursing orientation, and ongoing staff education. The organization should also promote regular audits, monitoring, and staff feedback to identify lacking areas and facilitate prompt improvement. Lastly, the project team must monitor fall rates in the unit, documentation compliance, charting time, injuries, and emerging costs to determine whether the improvements are sustained.
Recommended Citation
Tabiri, Nana A., "Implementing a Risk-Stratified Fall Prevention Bundle to Reduce Inpatient Falls," (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 81.
https://fuse.franklin.edu/dnp-project/81
Rights
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