Date of Degree

Summer 2025

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. Amanda Graham

Abstract

Problem: Falls among older adults residing in long-term care facilities continue to rise, resulting in injuries that contribute to adverse outcomes, a reduced quality of life, and increased healthcare costs. Despite existing safety interventions, falls persist, indicating a gap in effective, sustainable fall prevention strategies. Repeated failures to reduce falls among adults aged 65 years and older highlight the need for a structured, evidence-based approach aimed at addressing this critical patient safety issue.

Aim of the Project: The aim of this project was to reduce falls and fall-related injuries by 25% for older adults residing in a long-term care facility over a 10-week period through the implementation of an evidence-based fall prevention bundle.

Review of the Evidence: A comprehensive literature review supported that multifaceted fall prevention bundles with demonstrated effectiveness exist in long-term care settings. Studies emphasize that fall prevention interventions are more successful when combined with the Plan, Do, Study, Act (PDSA) model for quality improvement (QI) during implementation in clinical settings.

Project Design: This project utilized a QI model aimed at addressing practice challenges in healthcare in conjunction with the OhioHealth Change Management model to facilitate stakeholder engagement. The interdisciplinary team coordinated the planning, education, and implementation of the evidence-based bundle. PSDA cycles were used to drive small tests of change to implement the updated fall prevention bundle. Each successive PDSA cycle strengthened staff engagement, increased the effectiveness of the fall intervention bundle, and fostered continuous improvement in patient safety practices.

Intervention: The evidence-based approach used for this project employed three nursing and team strategies: (1) hourly rounds to ensure the four P’s (pain, placement, potty, and positioning) were addressed, (2) all patient needs were met before leaving the room, and (3) proactive team collaboration to prevent additional falls when patients experience a functional decline or when safety concerns were identified. These strategies promoted consistent care delivery and a safer environment by addressing risks in real time. The team collected data weekly on falls and staff compliance, allowing real-time evaluation and strategy adjustments.

Significant Findings/Outcomes: The evidence-based fall bundle and teamwork contributed to a 32% reduction in falls over 10 weeks and eliminated major injuries. The QI project aligned with the Institute for Healthcare Improvement’s (IHI) Six Aims for Healthcare Improvement by improving safety, outcomes, and care quality through evidence-based strategies. Sustainability requires ongoing engagement, interprofessional collaboration, and adoption into daily practice. The team continues to demonstrate a strong commitment to sustaining these improvements through active participation, shared accountability, and continued focus on patient safety.

Rights

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