Date of Degree

Fall 2024

Document Type

DNP Scholarly Project

Academic Department

School of Nursing

Degree Type

Doctoral

Degree Name

Doctor of Nursing Practice

First Advisor

Dr. Melanie Brewer

Second Advisor

Dr. Brandee Temmis

Abstract

Problem:

Patient falls represent a critical issue that incurs significant health and economic burdens for both individuals and healthcare organizations. Annually, falls and fall-related injuries are responsible for nearly 3 million emergency room visits and 1 million hospitalizations, costing an estimated $50 billion. Evidence suggests that a multi-factorial approach—often referred to as a "fall bundle"—is effective in reducing the incidence of falls. However, staff non-compliance with this bundle can undermine its effectiveness.

Aim of the Project:

The project aimed to reduce the incidence of falls by enhancing staff compliance with fall prevention measures through audits and feedback conducted by designated fall champions.

Review of the Evidence:

A comprehensive literature review indicates that conducting audits and providing feedback are effective strategies for enhancing staff compliance with care standards, such as the fall bundle. Additionally, engaging fall champions has been shown to improve compliance and reduce the incidence of falls.

Project Design:

This quality improvement project utilized the OhioHealth Change Management Model to develop and train the change team, enhance role clarity, outline execution plans, and assess both team and staff readiness. The Plan-Do-Study-Act (PDSA) cycle was employed to conduct data reviews, implement modifications, and evaluate outcomes.

Intervention:

The fall champions utilized an audit tool to conduct weekly audits to assess staff compliance with the fall prevention bundle. Feedback was provided as needed to reinforce the importance of these measures and their role in enhancing patient safety.

Significant Findings/Outcomes:

The unit achieved a compliance rate exceeding 70% with the fall prevention bundle, and there were no fall incidents during the project. However, the team did not examine the impact of the timing of audits, such as differences between day and night shifts or weekdays versus weekends.

Implications for Nursing:

Achieving a high compliance rate with the fall prevention bundle, along with the absence of falls during the project implementation, suggests that the interventions were effective. This project aligns with the Institute of Medicine’s Six Domains of Healthcare Quality by reducing the number of patient falls, thereby enhancing patient safety and overall care quality.

Rights

CC BY-NC-SA 4.0

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