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: Inpatient falls on a 48-bed orthopedic medical-surgical unit exceeded the organizational benchmark. Before implementation, the unit fall rate was 5.34 falls per 1,000 patient-days, compared with the benchmark of 2.45. Variation in bedside communication, documentation, and patient understanding created an evidence-to-practice gap.
Aim of the Project: The project aimed to reduce inpatient falls by implementing the Fall TIPS program to improve the reliability of individualized fall-prevention planning and integration of evidence-based strategies into daily nursing workflows.
Review of the Evidence: Evidence supports multifactorial fall-prevention strategies that combine individualized risk assessment, patient education, visual cues, and shared decision-making. Fall TIPS was selected because it translates fall-risk data into a visible bedside plan, promotes nurse-patient alignment, and reinforces patient-specific prevention strategies during routine care.
Project Design: A quality improvement design guided by the Institute for Healthcare Improvement Model for Improvement was used. One PDSA cycle supported workflow testing and refinement of the poster completion process. The OhioHealth Change Management Model guided engagement, readiness assessment, communication, adoption, and sustainment. Measures included fall rates per 1,000 patient-days, total falls, falls with injury, process fidelity, readiness, and feasibility.
Intervention: Fall TIPS was implemented over 12 weeks and included staff education, individualized fall-risk assessment, patient and caregiver education, bedside visual tools, teach-back, electronic health record documentation, weekly audits, and real-time coaching.
Significant Findings/Outcomes: The combined post-implementation fall rate increased from 3.12 to 4.75 falls per 1,000 patient-days; however, the monthly rate declined from 7.01 in June to 2.08 in July. Documentation compliance reached 92.4%, teach-back 89.9%, poster accuracy 86.1%, and individualized patient education 83.9%. Poster completion was 78.9% overall, with department nurses achieving 89.6%. Readiness for change increased from 4.08 to 4.35.
Implications for Nursing: Fall TIPS improved implementation reliability and individualized fall-prevention communication, although sustained reductions in fall rates were not achieved during the initial project period. The project demonstrates how standardized bedside tools can support consistent nursing practice and patient participation in fall prevention. Findings support continued audit feedback, coaching, and onboarding for non-core staff, as well as outcome monitoring to determine whether stronger process reliability improves fall outcomes over time.
Recommended Citation
Zobell, Jeremy, "Implementation of the Tailored Interventions for Patient Safety (TIPS) Program to Reduce Falls" (2026). All Doctor of Nursing Practice (DNP) Scholarly Projects. 100.
https://fuse.franklin.edu/dnp-project/100
Rights
Copyright, all rights reserved
Included in
Nursing Commons, Patient Safety Commons, Quality Improvement Commons
