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, DNP, MSN, RN, NE-BC
Second Advisor
Lydia Forsythe, PhD, MA, MSN, RN, CNOR
Abstract
Problem: Hospitalized patient falls cause physical, psychological, and financial harm and persist despite prevention bundles. A Midwest Ohio acute medical unit experienced higher-than-benchmark fall rates (1.53–7.58 falls/1,000 patient days; unit rate 113% of the national median), with a rising trend in FY25. Reliance on the Schmid tool and existing interventions lacked structured patient/family engagement, as well as comprehensive medication assessment, leading to under-recognition of risk and limited nurse-driven prevention.
Aim of the Project: The aim of the project was to reduce inpatient fall rates and fall-related injuries on a medical unit by implementing the Agency for Healthcare Research and Quality Fall-Tailored Interventions for Patient Safety (TIPS) toolkit over 12 weeks, increasing patient/family engagement and integrating the toolkit into bedside workflows.
Review of the Evidence: The evidence supports multifactorial, patient-centered interventions and stakeholder engagement in reducing hospital falls. Significant reductions in total and severe falls have been documented with the use of Fall TIPS. Other studies show variable outcomes when nurse-driven measures exclude patient collaboration. Many studies are limited by small samples and limited diversity, indicating the need for pragmatic quality improvement (QI) evaluations.
Project Design: A multidisciplinary QI initiative used the Plan-Do-Study-Act (PDSA) cycles and the OhioHealth Change Management model. Staff education included licensed and unlicensed personnel. Fall TIPS infographics were integrated into admissions and bedside shift reports, with weekly audits, daily shift huddles, and secure de-identified data collection. Process, outcome, and balancing measures were monitored.
Intervention: Laminated Fall TIPS infographics were completed with patients at admission and updated during bedside shift reports twice daily. PDSA-driven small tests of change addressed placement and completion barriers. Leadership audits and weekly KPI reporting reinforced compliance.
Significant Findings/Outcomes: The total fall rate decreased from 5.05 to 4.45 per 1,000 patient days (12% reduction); the injury fall rate decreased from 2.88 to 1.47 per 1,000 patient days (49% reduction). Falls decreased from nine to four during the implementation period. Bedside shift report compliance increased by 40%. Project supply costs were $125; estimated cost avoidance from three fewer falls was approximately $187,581.
Implications for Nursing: Embedding Fall TIPS into bedside workflows enhances patient engagement, communication, and safety culture, resulting in measurable reductions in falls and injuries. Nurse-led, leadership-supported implementation using PDSA cycles is a low-cost, scalable strategy to improve patient-centered fall prevention and advance DNP and Triple Aim goals.
Recommended Citation
Poindexter, Lauren, "Fall Reduction Utilizing Fall Tailored Intervention for Patient Safety in Acute Care" (2025). Doctor of Nursing Practice (DNP) Scholarly Project. 44.
https://fuse.franklin.edu/dnp-project/44
Rights
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