Date of Graduation

Winter 12-16-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Patient falls have been an issue in hospital settings for many years. Patient falls not only lead to increased costs for the hospital, but affects the safety and care for patients. Many studies have assessed potential, contributable factors leading to falls, fall risk assessment tools, and fall prevention interventions in different settings. However, there are limited studies done in inpatient psychiatric settings. The acute-psychiatric unit at a large metropolitan hospital has seen an increase in falls in the last year, yet current interventions have not addressed this issue.

The purpose of this project is to conduct an assessment of the unit’s current fall risk assessment tool, interventions, and processes, while collecting and analyzing data of each fall and patients who have fallen. The results will help determine potential causes to the increased falls and help lead to solutions that can prevent future falls. Data was collected from patients’ chart reviews, Unusual Occurrence Reports, and RN interviews. Analysis of data show that many patients were not identified as a fall risk at the time of his or her fall, while nurses on the unit had differing definitions of the current falls protocol and policy on the unit.

The following interventions are recommended: education on the use of a fall risk assessment tool that is appropriate for the acute-psychiatric population, instead of the current Schmid Fall Risk Assessment Tool that is used for all departments of the hospital and training for nurses on the unit to provide a clearer understanding of the unit’s falls protocol and policy and fall prevention interventions.