Date of Graduation

Fall 8-7-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Background: Due to the lack of appropriate fall prevention measures in an acute rehabilitation unit, there has been a notable increase of patient fall occurrences within a 6 month period. The purpose of this practice improvement project was to reduce patient falls within a 36-bed unit, using visual aids and effective communication among nursing staff. The multi-disciplinary members involved licensed nurses, nursing assistants, nursing supervisors, director of nursing, and executive administrator. Methods: The method used to implement this project included a literature search, informational interviews and staff surveys, and prioritization of interventions by the team. Project implementation was guided by the Diffusion of Innovation change theory of Everett Roger that underscores the need to assess different levels of staff engagement and readiness to change. An initial analysis of data related to patient falls was retrospectively reviewed over a period of 6 months. Upon review of the existing fall risk assessment tool, further interventions were suggested for improvement. Interventions: The nursing staff was questioned to evaluate their knowledge of fall prevention and their learning needs to provide more effective communication. As a result, staff huddles and visual aids were prioritized and implemented. Results: After educating the nursing staff on the prevention of falls and implementing new measures to decrease the occurrence of such events, the following results were attained. Over a 6 month period, the average monthly fall rate was 7.1. After the intervention over a 4-week period falls decreased by 30%. Conclusion: Preventative strategies, including huddles and visual prompts, were utilized to successfully reduce patient falls. Heightened awareness and consistent accountability by professional staff can result in a significant decrease of such events.