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: Falls are a significant patient safety concern among hospitalized older adults. The existing fall risk assessment did not evaluate medications, creating a gap in identifying fall-risk-increasing drugs (FRIDS).
Aim of the Project: The aim was to improve FRID identification by implementing a medication-focused fall risk assessment tool (MFRAT) for older adults admitted to an orthopedic and neurological medical-surgical unit. The American Society of Consultant Pharmacists & National Council on Aging Falls Risk Checklist was the chosen tool.
Review of the Evidence: Evidence identified three recurring themes: standardized MFRAT use, FRID identification, and healthcare worker education on FRIDs. Findings supported that identifying and optimizing high-risk medications was essential to reducing inpatient falls.
Project Design: A quality improvement design using the Plan-Do-Study-Act (PDSA) framework guided implementation and evaluation. The OhioHealth Change Management Model was used concurrently to support staff engagement, readiness, workflow changes, and sustainability. Weekly data was collected through MFRAT audits, medical records, staff education records, and an Excel tracking tool.
Intervention: The MFRAT was integrated into the RN admission workflow. RNs received education on identifying FRIDS and MFRAT completion. Implementation was supported through a pharmacy-developed FRID tip sheet, documentation of four or more FRIDs, and fall-precaution enhancement when FRIDs were identified despite the patient not initially scoring as a high fall risk. Ongoing huddles, workflow support, and weekly monitoring reinforced adherence and addressed implementation barriers.
Significant Findings/Outcomes: Staff education reached 94% of RNs, exceeding the 90% goal. MFRAT completion improved from 85% at baseline to 100% by the end of implementation. Among the 137 patients sampled, 68% had at least one FRID identified, and 32% had four or more FRIDS. Five patients initially not identified as high fall risk had four or more FRIDS; one subsequently received increased fall-prevention interventions. The six-week implementation did not demonstrate measurable financial savings, although the intervention has potential long-term cost benefits through fall prevention.
Implications for Nursing: Findings demonstrated improved FRID identification and supported patient-centered fall prevention. Although the MRFAT used was not the optimal tool for the hospital setting, integrating medication assessment into the electronic health record with prompted tasks may improve adherence and sustainability.
Recommended Citation
Shultz, Jill, "Implementing Medication-Focused Fall Risk Assessment to Reduce Falls in Acute Care" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 90.
https://fuse.franklin.edu/dnp-project/90
Rights
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