Date of Degree
Fall 2025
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Brandee Temmis
Abstract
Problem: Falls are widely recognized as a leading cause of injury and hospitalization among older adults, with geriatric psychiatric patients at particularly high risk due to polypharmacy, cognitive impairment, and mobility challenges. At the project site, baseline audits revealed inconsistent use of structured fall risk tools, limited nurse-driven medication review, and gaps in post-fall documentation. The absence of an embedded electronic health record feature for medication review highlighted a significant practice gap requiring intervention.
Aim of the Project: The aim of this quality improvement (QI) project was to reduce fall risk in a geriatric psychiatric hospital through structured post-fall medication reviews, improved fall risk reassessments, and standardized documentation practices.
Review of the Evidence: The American Geriatrics Society Beers Criteria (2023) identifies high-risk medications linked to falls. Research demonstrates that nurse-led medication reviews and interdisciplinary fall huddles enhance patient safety. Evidence supports structured tools, leadership rounding, and post-fall analysis as strategies to reduce harm and reinforce a safety culture.
Project Design: The project applied the Plan-Do-Study-Act (PDSA) cycle to guide iterative improvement and the OhioHealth Change Management Model to strengthen leadership engagement and staff readiness.
Intervention: The intervention included implementation of the Wilson–Sims Fall Risk Assessment Tool, a structured Post-Fall Checklist, and a nurse-led manual medication review using a standardized guide. Leadership-supported fall huddles and improved documentation practices were incorporated into routine care.
Significant Findings/Outcomes: Post-implementation data demonstrated a four-fold increase in medication review compliance, universal reassessment using the Wilson–Sims tool, and consistent completion of post-fall huddles. Although fall rates varied, process improvements strengthened safety practices and established a foundation for continued fall reduction efforts within existing resources.
Implications for Nursing: The QI project reinforces the role of advanced practice nurses as leaders in patient safety and highlights the effectiveness of evidence-based tools in psychiatric geriatric settings. Structured medication reviews and standardized documentation strengthened accountability, improved interdisciplinary communication, and supported alignment with national best practices.
Recommended Citation
Johnson, Regina, "Quality Improvement initative to Reduce Falls Among Geriatric Patients in the Inpatient Mental Health Setting" (2025). Doctor of Nursing Practice (DNP) Scholarly Project. 43.
https://fuse.franklin.edu/dnp-project/43
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