Date of Graduation

Winter 12-12-2025

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Dr. Cynthia Huff

Abstract

Problem: The inconsistent use of a Fall TIPS tool in a 750-bed hospital has resulted in eight preventable patient falls in the fiscal year 2023-2024. Preventable injuries from falls increase hospital length of stay, cause patient harm, and lead to patient and staff dissatisfaction.
Context: Staff engagement with the Fall TIPS tool on a cardiac unit is limited. Opportunities to incorporate the tool into standardized workflow and increase patient involvement are necessary to decrease accidental falls in this population. Intervention: An evidence-based intervention was implemented to educate staff, patients, and caregivers on the purpose, use, and responsibilities of the Fall TIPS tool to prevent unintended falls in a cardiac unit.
Measures: Outcome measures include a 50% reduction in total falls by the end of fiscal year 2025. Process measures include improved utilization of the Fall TIPS tool. Balancing measures will monitor for unintended consequences, such as reduced mobility or skin breakdown, using incident reports.
Results: During the four-week intervention period, Unit A showed improved compliance with Fall TIPS poster completion, averaging 83.3% across 269 audited rooms. One fall (without injury) occurred during the intervention period, which meant that the goal of a 50% reduction in falls was not met. However, there has been a meaningful decrease in falls with injury, which reflects positive progress toward improving patient safety.
Conclusions: Established a foundation for sustainable fall prevention to expand hospital-wide. Long-term plans include integrating Fall TIPS into onboarding and annual training to support lasting improvements in patient safety

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