Date of Completion
Fall 2026
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Corrine Cochran
Abstract
Problem: Adult inpatient falls are a persistent patient safety concern that can result in injury, prolonged hospitalization, and increased healthcare utilization. The identified medical-surgical unit had a baseline fall rate of 4.88 falls per 1,000 patient days, exceeding the organizational goal of fewer than 3.0 falls per 1,000 patient days. An organizational assessment identified inconsistent fall-risk assessment, documentation, patient education, and individualized prevention strategies as practice gaps.
Aim of the Project: The aim was to reduce the inpatient fall rate to fewer than 3.0 falls per 1,000 patient days through implementation of the CDC’s Stopping Elderly Accidents, Deaths & Injuries (STEADI) fall prevention toolkit over 12 weeks.
Review of the Evidence: Evidence identified inpatient falls as a multifactorial, systems-based problem associated with communication, patient education, toileting, call-light response, and staff education. The literature supported standardized fall-risk assessment, individualized interventions, patient and staff education, interdisciplinary collaboration, and continuous quality improvement as components of effective fall prevention.
Project Design: This quality improvement project used the Plan-Do-Study-Act (PDSA) framework and OhioHealth Change Management Model to guide implementation, stakeholder engagement, evaluation, and sustainability.
Intervention: The CDC STEADI toolkit was incorporated into routine nursing workflows through standardized screening, the Stay Independent Assessment Checklist, Timed Up and Go assessments, medication reviews, patient education, individualized fall-prevention interventions, staff education, and ongoing audit and feedback.
Significant Findings/Outcomes: The fall rate decreased from 4.88 to 2.4 falls per 1,000 patient days, representing a 50.8% reduction and exceeding the project goal. Staff education reached 100%. Among eligible patients at risk for falls, STEADI screening reached 92%, patient fall-prevention education reached 93%, patient understanding reached 95%, and high-risk medication reviews reached 89%. Staff productivity remained within the predetermined balancing-measure threshold. Organizational readiness improved across all measured domains.
Implications for Nursing: Implementation of standardized, evidence-based fall-risk assessment strengthened nursing surveillance, individualized clinical decision-making, interdisciplinary communication, and patient safety. Continued leadership oversight, staff education, competency validation, audit and feedback, and monitoring of fall-related outcomes are necessary to sustain the practice change. The project demonstrates doctoral-level nursing practice through evidence translation, systems thinking, quality improvement, interdisciplinary collaboration, and sustainable organizational change.
Recommended Citation
Graham, Kevin, "CDC’s STEADI Fall Toolkit to Decrease Adult Inpatient Medical-Surgical Fall Rates" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 83.
https://fuse.franklin.edu/dnp-project/83
Rights
Copyright, all rights reserved
