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
Dr. Kristie Lowry
Second Advisor
Dr. Melanie Brewer
Abstract
Problem: Falls remain a significant patient safety concern in hospitals. In an inpatient oncology unit at a large academic medical center, falls increased from 33 in 2024 to 46 in 2025, while the fall rate increased from 2.86 to 3.95 falls per 1,000 patient days. A gap analysis revealed that only 5% of high fall-risk patients had fall boards and visual cues in place.
Aim of the Project: The aim of this quality improvement (QI) project was to increase the utilization of fall boards and visual cues for high fall-risk patients through implementation of a standardized fall prevention education bundle for registered nurses (RNs) over 12 weeks.
Review of the Evidence: Evidence supported multifaceted fall prevention strategies emphasizing staff education, patient engagement, visual identification of fall-risk patients, and standardized protocols. The Agency for Healthcare Research and Quality (AHRQ) Fall Tailoring Interventions for Patient Safety Toolkit identified visual cues and fall boards as evidence-based interventions.
Project Design: This QI project utilized the Plan-Do-Study-Act (PDSA) framework and the OhioHealth Change Management (OHCM) model to guide implementation. Baseline audits assessed compliance with fall boards and visual cues, followed by staff education, weekly audits, feedback, and continuous monitoring. Outcome and process measures were tracked throughout the 12-week implementation period.
Intervention: A standardized fall prevention education bundle was delivered to RNs, focusing on fall-risk assessment, proper use of fall boards and visual cues, patient engagement, and prevention strategies. Weekly audits and visual feedback of compliance data reinforced practice changes.
Significant Findings/Outcomes: Ninety-one percent of RNs completed the education bundle, exceeding the target of 74%. Combined compliance with fall boards and visual cues increased from 28% pre-intervention to 52% post-intervention, a 24% improvement. Fall board utilization demonstrated the greatest improvement, while visual cue compliance remained consistently high.
Implications for Nursing: Standardized fall prevention education improved nursing adherence to evidence-based fall prevention measures and enhanced awareness of patient fall risk. Ongoing education, leadership support, and workflow integration are essential to sustain improvements, strengthen patient safety, reduce fall-related harm, and support broader implementation across inpatient settings.
Recommended Citation
Miller, Rachel, "Fall Prevention in the Inpatient Oncology Unit Using Fall Boards and Visual Cues" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 96.
https://fuse.franklin.edu/dnp-project/96
Rights
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