Digital Repository Masters Theses Spring 2026 A Quality Improvement Project to Reduce Falls on an Inpatient Rehabilitation Unit Megan Taggart Weber State University Follow this and additional works at: https://dc.weber.edu/collection/wsudoctoral Taggart, M. 2026. A Quality Improvement Project to Reduce Falls on an Inpatient Rehabilitation Unit. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/WSUDoctoral This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP A Quality Improvement Project to Reduce Falls on an Inpatient Rehabilitation Unit Project Title by Megan Taggart Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 15th, 2026 Date BSN, RN, MSN Student April 15th, 2026 Student Name, Credentials (electronic signature) Date Angela Page, DNP, APRN, PPNP-BC 4/25/26 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE 4/25/26 Anne Kendrick Date (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. 1 A Quality Improvement Project to Reduce Falls on an Inpatient Rehabilitation Unit Megan Taggart Annie Taylor Dee School of Nursing Weber State University Dr. Angela Page MSN Project February 15th, 2026 2 Abstract Purposes/Aims: This project aims to reduce patient falls in a local rehab unit by implementing evidence-based fall-prevention education and interventions tailored to each patient’s individual risk factors and score. Rationale/Background: Falls are costly and a leading cause of preventable injury among patients throughout the world. Older adults or adults learning to regain mobility are at an increased risk. Evidence-based fall prevention education and strategies are necessary to reduce fall rates and improve patient safety. Methods: To address fall prevention issues, staff and patient education will be provided, and will be from the Agency for Healthcare Research and Quality. These measures aim to increase staff and patient confidence in preventing falls. A pre- and post-implementation survey, along with a fall knowledge test, will be administered to staff to gauge the effectiveness of the interventions. Additionally, a fall data sheet will be used to track falls, allowing pre- and postintervention fall rates to be compared. The Johns Hopkins Nursing Evidence-Based Practice Model served as a framework for this project. Results: This project is expected to reduce the patient fall rate through the integration of evidence-based staff and patient education, and tailored, personalized fall-prevention interventions. Conclusions: Implementing evidence-based education, along with personalized prevention interventions, will help staff prevent patient falls, thereby increasing overall patient safety and satisfaction scores. Upon successful completion of the pilot, it is projected that fall prevention expansion would occur facility-wide, unit by unit. Keywords: Education, personalized prevention interventions, safety, falls. 3 A Quality Improvement Project to Reduce Falls on an Inpatient Rehabilitation Unit Patients face many challenges while admitted to the hospital, and falling during an inpatient stay can add further complications. Worldwide, patient falls in the acute care setting are a chronic and often preventable problem (Morris et al., 2024). Falls are influenced by a variety of factors, including the patient’s condition, environment, and the interventions in place at the time of the fall (Jarden et al., 2024). Due to the intensive rehabilitation work and aim to increase patients’ independence levels, those on acute rehabilitation (rehab) units are at increased risk for falling (Miles et al., 2025). The goal of this project is to reduce falls in a local acute rehab unit by integrating team-centered education and evidence-based fall prevention strategies. Statement of Problem In the hospital setting, falls are the most common cause of avoidable patient injury (Agency for Healthcare Research and Quality, 2021). In the United States alone, approximately one million hospitalized patients fall each year (Twibell et al., 2023). Not only are falls expensive, costing around 50 billion yearly, but they can also result in injury to the patient, and in extreme cases, result in patient death (Twibell et al., 2023). While most patients in hospitals are considered a fall risk, many falls that occur are either in the older population, those with mental impairment, or those with long-term conditions (Morris et al., 2024). Mikos et al. (2021) found that the highest incidence of patient falls occurred in the rehabilitation (rehab) unit. In addition, Miles et al. (2025) noted that patients in a rehab unit are at greater risk of falls. This is due to the increased independence and activity patients experience during rehab. 4 A patient safety director at a community hospital in northern Utah found that, upon analyzing the hospital’s fall rate, many falls occurred in the inpatient rehab unit. Within one month, there were 22 inpatient falls. Of the 22 falls, nine were on the rehab unit. One fall resulted in serious harm to the patient, requiring additional care (M. Barr, personal communication, August 2025). Significance of the Project Reducing the fall rate on the rehab unit will improve patient outcomes, increase patient satisfaction, and enhance patient safety throughout the unit. Morris et al. (2024) found that patients who received fall prevention interventions experienced better outcomes than those who did not. Patient satisfaction scores increase with high-quality care (Durgan & Aksoy, 2025), which includes ensuring safe clinical practice during their hospital stay. Evidence-based fall prevention strategies have been shown to reduce fall rates, thereby enhancing overall patient safety (Khoja & Moosa, 2023). Review of the Literature A literature review was conducted to find evidence-based fall prevention methods. The PICOT question guiding the literature review is: For registered nurses working on inpatient rehabilitation units, how does the implementation of evidence-based fall prevention strategies, compared to current standard protocols, affect the rate of patient falls over 6 months? Education for staff and patients, as well as the implementation of multiple patient-specific fall-prevention interventions, were themes throughout the literature review. Framework The Johns Hopkins Evidence-Based Practice Model for Nurses (JHEBP) will be followed for this project. The JHEBP model comprises three phases: inquiry, practice, and learning 5 (Bissett et al., 2025). This framework was created to ensure that up-to-date research findings are incorporated into patient care (Gawlinski & Rutledge, 2008). A key aspect of this model involves the use of evidence to inform decision-making (Gawlinski & Rutledge, 2008). To reduce the fall rate on an inpatient acute rehab floor, research-supported education and interventions will be implemented. Inquiry is the first phase of the JHEBP model. To determine the most effective fall prevention techniques, a literature review is conducted. This requires searching current literature for evidence-based methods to reduce falls. Once the inquiry is complete, research-validated interventions can be instituted. This project will implement the interventions in a local rehab unit. The learning phase of this project will be guided by real-time evaluation of the interventions and by assessing their effectiveness in reducing the patient fall rate. Strengths and Limitations The three phases of the Johns Hopkins model provide a concise layout that makes it easy to follow and are a key strength of this model (Branson, 2025). Using the three phases as a guide, inquiry, practice, and learning, this model facilitates the creation and application of quality improvement endeavors (Branson, 2025). It is user-friendly and straightforward, with clear steps laid out. To prevent inpatient falls, scientifically substantiated interventions must be used. The Johns Hopkins Model provides a framework that integrates research, the implementation of evidence-based interventions, and the evaluation of lessons learned from the project into practice. The Johns Hopkins Model for Evidence-Based Practice requires conducting research to determine best practices. Finding and identifying empirically grounded practice requires that the individual conducting the research possesses the necessary knowledge and understanding to sift 6 through the evidence (Dusin et al., 2023). When there are multiple sources of information, it is essential to know how to distinguish between them to identify data-driven practices. This can be considered a limitation when using this model as a framework for evidence-based practice. Search Strategies A thorough review of the literature was conducted to identify current evidence and best practices. This search was performed using Weber State University’s Stewart Library’s One Search, as well as CINAHL and Google Scholar. To ensure that the most current evidence was searched, articles published between 2020 and 2025 were included. Keywords used in the search include “inpatient falls”, “preventing falls”, “falls prevention”, “fall prevention education”, “interventions to prevent falls”, “falls on rehabilitation units”, “evidence-based fall prevention strategies”, and “patient falls education”. Synthesis of the Literature Several themes emerged during the literature review. Firstly, preventing falls requires comprehensive staff education and training. Second, it is vital to provide ongoing education to patients and their families regarding fall prevention measures and techniques. Finally, effective fall prevention requires a multifactorial approach. Fall Prevention Education and Training for Staff The literature shows that staff education is a crucial factor in the success of fall prevention programs. Mayorga et al. (2022) identified nursing knowledge deficits related to fall metrics during a root cause analysis. Following the rollout of an educational intervention, nurses demonstrated a deeper understanding of fall risks and their prevention. Along those same lines, Akhiwu et al. (2025) found that staff adherence to fall prevention techniques increased when education on prevention strategies was regularly provided. Similarly, Miles et al. (2025) found 7 that educating staff on the importance of the teach-back method was associated with a reduction in falls. Rogers et al. (2021) showed that training staff on the benefits of mobility over bed rest for patients reduces patient falls. While the benefits of staff education and training have been proven, barriers to implementing fall prevention education remain. McKercher et al. (2024) highlighted the lack of guidance and clear protocols for delivering and implementing patient and staff falls education as one such obstacle. Challenges related to teamwork and communication were also identified as hindrances. Jarden et al. (2024) observed that patients noticed a lack of staff attentiveness to safety concerns, while McLennan et al. (2024) reported confusion among staff regarding their roles and responsibilities in fall prevention. These studies indicate that staff need training and education in patient-centered communication, fall risk assessment, and teamwork to support a successful fall prevention program. Fall Prevention Education for Patients An additional component of fall prevention is patient education. McLennan et al. (2024) reinforced that, for fall prevention to be effective, the responsibility must be collaborative, shared between staff and patients. Morris et al. (2024) observed that patients are most at risk of falling within the first 48 hours of admission. This underscores the importance of delivering fall prevention education immediately upon admission. Moreover, Twibell et al. (2023) indicated that personalized education, customized to the patient’s needs and risk level, improves patients’ understanding and compliance with fall prevention. The reinforcement of fall-prevention education is mandatory to prevent falls. A case study by the South Carolina Nurses Association (2024) found that nurses may be held responsible for patient falls when prevention education is not appropriately reinforced. Effective 8 education should include precise instruction on fall-prevention techniques and highlight the importance of calling for help before ambulating (South Carolina Nurse Association, 2024; Montero-Odasso et al., 2022). In addition to reducing the fall rate, patient education has multiple positive effects. Patients reported that fall prevention education increased their confidence and motivated them to engage in preventative measures (Hill et al., 2024). Together, these studies call attention to the importance of providing timely, personalized, and regularly reinforced fall prevention education. Multifactorial Approach An important part of an effective fall prevention program is implementing multiple evidence-based interventions. The Fall Prevention Toolkit by the Agency for Healthcare Research and Quality (2021) found that patients’ fall risk should be assessed first, and interventions should be implemented based on the identified risk level. Additionally, a personalized fall-prevention plan should be created for each patient. The personalized plan should combine education with interventions tailored to the individual’s fall risk score and needs. Education is an important piece of the multifactorial approach to reducing patient falls. Morris et al. (2024) found that staff trained to deliver evidence-based fall prevention education to patients reduced the fall rate. Likewise, Twibell et al. (2023) noted that education, when paired with a fall-prevention video and targeted interventions, was beneficial for keeping patients safe. When coupled with other interventions, medication management can help reduce falls. Seppala et al. (2022) established that deprescribing medications is effective when combined with preventative fall interventions. The findings jointly indicate that preventing falls requires a coordinated, multifaceted approach; singular interventions are not enough. Implementing patient 9 risk assessments, personalized education, deprescribing medications, and individualized interventions are crucial for reducing patient falls. Summary of Literature Review Findings and Application to the Project Education for both staff and patients, along with multifaceted prevention strategies, is essential to reducing patient fall rates. Staff provided with fall risk and prevention education demonstrated increased confidence in their ability to keep patients safe. When patients are educated about their fall risk and the interventions in place, they are more motivated to seek help and utilize the provided interventions. A multifaceted approach, when combined with education, has effectively reduced the fall rate. Increasing staff and patient understanding and confidence through appropriate education and a patient-specific approach will reduce fall rates on a local rehabilitation unit. Project Plan and Implementation The purpose of this project is to reduce the fall rate in a local rehabilitation (rehab) unit by implementing staff education and training, providing education for both patients and their families, and employing a multifaceted approach. To accomplish this, department leaders and hospital administration will meet to discuss research from the literature review and the proposed interventions. Subsequently, training and education will be developed and implemented for both staff and patients. Interventions placed for patients will be personalized to the patient’s fall risk and will be multifaceted. The new fall plan will be put into policy at the end of the pilot. Plan and Implementation Process Baseline falls data, including the hospital-wide rate of falls compared to the rehabilitation unit and the severity of falls, will be discussed at a meeting with department leaders and administration. This data will be collected by the director of patient safety and the patient safety 10 specialist and entered into the data sheet (see Appendix A). The problem will be presented at a falls committee meeting, along with proposed solutions that include patient education (see Appendix B) within a specified time frame (Morris et al., 2024), staff education (see Appendices C and D) (Akhiwu et al., 2025), and a personalized, multifaceted approach (see Appendix E) (Agency for Healthcare Research and Quality, 2021). This meeting aims to highlight the significance of the problem and to gain support for the proposed solutions. Once buy-in from hospital leaders, administration, and the falls committee has been secured, research findings and recommendations will be discussed in depth. Hospital administration and unit leadership will assist in determining the appropriateness of interventions for implementation in the unit. They will have the final say in the overall implementation of the interventions. As collaboration with leaders progresses, an action plan will be developed for implementation within the unit. A six-month timeline will be proposed. Parties will be assigned responsibilities and tasks. To assess the effectiveness of the implemented interventions, the fall rate per 1000 patient days will be monitored consistently (see Appendix A). The harm level of any fall that occurs will also be analyzed (see Appendix A). Concurrently, a pre-implementation survey (see Appendix F) and a fall knowledge test (see Appendix G) will be administered to staff before any fall prevention education. This survey will assess current staff confidence levels in providing falls education and interventions for patients. It will also gauge staff perception of falls. Staff training (see Appendices C and D) will take place over one month. It will include instruction on appropriate fall interventions, how to determine which interventions are needed on a case-by-case basis, and fall prevention education. These training sessions are mandatory for all 11 staff members working on the rehab unit. Fall champions will be assigned by the rehab unit director and manager to both day and night shifts to enable real-time problem-solving. They are to be an additional resource for unit staff in preventing patient falls. The fall champions will provide feedback to leadership and administration to inform adjustments during the implementation phase. After the allotted six-month implementation period, a post-implementation survey will be administered to participating staff. As with the pre-survey, the post-survey (see Appendix I) will assess staff confidence in providing falls education and interventions, as well as their perceptions of falls following six months of program implementation. The post-survey will offer staff the opportunity to provide feedback on the program, including what worked well, what did not, and any adjustments that they believe would be beneficial moving forward. The patient safety director will share findings from project implementation monthly with leadership and hospital administration at the falls committee meeting. What is working well and what needs adjustment will be discussed. In addition, a comparison of falls data from the preand post-implementation periods will be presented. The pilot’s effectiveness will be gauged and considered for hospital-wide dissemination by leadership and the administrative team. Interdisciplinary Team While patient safety is everyone’s responsibility, a team working together to keep patients safe is more effective and impactful than working alone. The use of a team approach to safety means more people are looking for potential hazards to patients, and it also reduces the burnout individuals can feel when working alone (Weller et al., 2024). The hospital has staff trained in different specialties, each providing a different perspective on preventing patient falls. 12 To that end, numerous individuals will contribute to this project. Those individuals include: the director and manager for the rehabilitation unit, physical and occupational therapists, registered nurses, patient care technicians, members of the falls committee, and patients. Each of these individuals has a vested interest in ensuring patient safety and reducing falls in the rehabilitation unit. In addition, each possesses certain skills and qualifications necessary to keep patients safe. Rehabilitation Unit Director and Manager. Achieving buy-in and support from the unit’s director and manager is vital to the program's successful implementation. Staff look to these individuals for guidance on changes occurring within the unit. Their reaction to those changes is closely observed to see whether they agree with what is being done. Together, the director and manager are key players in exemplifying and modeling staff changes. With their encouragement, the program is likely to receive greater support downstream. Physical and Occupational Therapists. Physical and occupational therapists play a major role in patient care on the rehabilitation unit. They make recommendations on the care the patient is receiving, including fall-prevention interventions. In addition, they possess a great deal of knowledge and expertise that is beneficial in keeping patients safe. Physical and occupational therapists are movement specialists and can evaluate what a patient can do safely and what they might need assistance with. Registered Nurses. Registered nurses are the primary point of contact for patients. They implement provider orders, which often include patient safety measures. As such, they can make recommendations to providers if they notice anything in the patient order set that could be changed to improve patient safety, particularly regarding potential falls. It is necessary to have 13 them on the interdisciplinary team, as they often observe and report things that might otherwise go unnoticed. Similarly, they ensure a safe environment within the patient’s room. Patient Care Technicians. When a call light goes off, patient care technicians are typically the first ones to respond. In conjunction, they often assist patients with activities of daily living, including showering and toileting. Both of those activities are where falls occur most frequently. Patient care technicians must be properly trained to assist patients with activities of daily living safely. Falls Committee Members. Every week, the falls committee meets to discuss falls that have occurred throughout the facility over the past week. This committee consists of unit leaders and managers from every area of the hospital. They provide deeper insight into the falls that occurred on their units and contribute information that has been discussed with their team following the falls. Valuable learning occurs when findings from falls in other units are discussed, providing insights that everyone can benefit from to prevent falls in their own unit. This committee, as part of the interdisciplinary team, adds numerous viewpoints that can be beneficial for implementation. Patients. Each patient comes onto the unit with a different level of ability and function. Patient buy-in is essential to keeping them safe. Without patient support, education can be provided and interventions implemented, but they will not be successful in helping keep the patient safe. Patients need to understand the importance of their role and be willing to take an active part in their own safety. When patients understand the importance of falls prevention interventions, they tend to be safer and achieve better overall outcomes (Hill et al., 2024). Description and Development of Project Deliverables 14 For this project, numerous deliverables are being utilized. Those include: a data collection sheet for falls, pre- and post-implementation surveys, a fall knowledge test, patient education, fall champion training, staff training, and a tip sheet for nurses. Each of these deliverables serves an important part in the implementation and evaluation of the project. Data Collection Spreadsheet. Collecting falls data is essential. This data spreadsheet (see Appendix A) will be used to track falls that occur on the unit during the six-month implementation period. Collecting and maintaining accurate data helps to paint a clear picture of what is working and what needs to change (The Council of Quality and Leadership, 2018). In addition, data collection can help inform decisions and point to issues before they become bigger problems down the line. Patient Education. The patient education utilized for this project (see Appendix B) is from the Agency for Healthcare Research and Quality (AHRQ). Morris et al. (2024) found that patient education was most impactful in keeping patients safe when delivered promptly after admission, ideally within the first 48 hours. This patient education tool from AHRQ is simple yet effective in helping patients stay safe in the hospital. In addition, it provides statistics on falls and why prevention is important for the patient to participate actively. Fall Champion and Staff Education. Akhiqu et al. (2025) observed that staff education improved overall adherence to fall prevention measures. AHRQ will provide education for unit champions (see Appendix C). Unit fall champions will receive additional training to ensure they possess the knowledge necessary to serve as a resource for unit staff. Champions will also attend staff training sessions to ensure consistency in education and to reinforce key concepts. All unit staff will participate in standardized fall prevention education (see Appendix D). This training is intended to increase staff understanding of fall prevention measures, thereby 15 improving confidence in maintaining patients’ safety. Enhanced education equips staff to properly educate patients on fall prevention, leading to improved patient outcomes. Education for unit champions and staff will be provided annually. Nurse Fall Tip Sheet. A multifactorial approach to falls, education, and patient-specific interventions (AHRQ, 2021) is important in keeping patients safe. The AHRQ TIPS sheets for nurses (see Appendix E) are used to develop a personalized fall-prevention plan for patients. Both the TIP sheet and the misconception sheet will guide nurses through identifying patient risk factors, creating a plan to reduce the risk of falling, and helping staff consistently carry out the plan for the patient. The TIPS sheet will be posted in the patient room for all staff to review and for the patient to reference. Pre- and Post-Implementation Survey and Fall Knowledge Test. Prior to staff education, a fall knowledge test (see Appendix G) and a pre-implementation survey (see Appendix F) will be administered. Upon project completion, a post-implementation survey will be given to staff (see Appendix H). Assessing staff confidence before and after interventions helps measure their effectiveness (GOV.UK, 2020). The surveys are important for gauging whether staff interventions positively affect staff courage in preventing patient falls and keeping patients safe. Timeline During a Fall Committee Meeting, the project will be presented to obtain buy-in from hospital leadership and administration. At that point, research findings and recommendations for a fall program on the rehab unit will be discussed. Collaboration will take place to establish the project implementation plan and present it to the staff. During this time, unit fall champions will be selected. This phase is expected to take 1 month. 16 The second month of the project will involve training and education specific to unit fall champions and all staff members on the rehab unit. This will include learning to assess a patient’s fall risk and determine appropriate interventions, as well as educating patients. Prior to training and education, which will occur yearly, a pre-implementation survey will be administered along with a fall knowledge test. Training will take place over one month and will be mandatory. Once training and education are complete, implementation in the unit can begin. This phase will last 6 months. During that time, fall metrics will be logged into the data sheet. The fall committee meets monthly and will discuss the project at each meeting, focusing on what is working well and what needs adjustment. After six months, the project will be evaluated. The project evaluation will include a post-intervention survey. The survey will also allow staff space to give feedback on the project and whether they would like to see anything done differently. Fall metrics will be analyzed over the six months to determine whether the rehab unit's overall fall rate improved. At this time, it will be determined whether this project is appropriate for rollout to other units throughout the hospital and whether any adjustments are needed to meet the unit's needs better. In summary, upon project approval, research findings will be disseminated to support unit-level implementation. Fall champions will be selected for the unit, and education and training will be provided to all rehab unit staff. The project will be implemented over six months and continually evaluated throughout. Upon completion of the pilot, it will be evaluated for application across the hospital. The appropriateness of hospital-wide execution will be based on the pilot’s effectiveness in increasing staff confidence in fall prevention and in reducing fall 17 incidents on the rehab unit. Hospital administration, in collaboration with unit leaders, will determine whether this will be implemented facility-wide. Project Evaluation Throughout the pilot of this project, it is essential to evaluate the impact and effectiveness. The evaluation of interventions can guide choices that improve patient outcomes and enhance individuals’ experience with healthcare (Skills for Health, 2025). Formative methods used include a pre- and post-implementation survey and ongoing evaluation throughout the pilot. Summatively, the fall rate per 1000 patient days will be used to assess the pilot’s overall success. Pre- and post-implementation surveys assess staff confidence levels before and after interventions. Using this as an evaluation method will help leaders determine whether the required educational materials and implemented interventions were effective in increasing staff confidence in preventing falls. Continuously evaluating the project enables necessary changes. In addition, the ongoing appraisal can help to identify problems and adjust parts of the pilot as needed early on, before they become bigger issues. Evaluating the fall rate per 1000 patient days assesses the intervention's overall outcome rather than its process. That number tells the administration whether the pilot was effective and, if so, how effective it was at reducing the fall rate. While the pre- and post-implementation surveys are subjective, the fall rate at the end of the pilot is objective data. It is based on facts and provides an accurate picture of the pilot's overall benefit. The Director of Patient Safety will be responsible for reviewing the data and survey results. Ethical Considerations 18 Ethical considerations for this project include patient safety and confidentiality, as well as ensuring staff well-being. This project aims to increase patient safety by reducing falls in the rehab unit through the implementation of research-proven methods. These will be put in place to support patient safety, and patient responses will be monitored. As fall data are collected, patient-identifying information will be removed, and the data will be maintained securely. Patients have the right to participate in their healthcare decisions and to be informed about the interventions in place to support them. To aid patient engagement and fall prevention, interventions specific to the patient will be placed visibly in the patient’s room and discussed daily with the patient. Staff will receive appropriate education on fall prevention and have access to resources, including fall champions, the unit manager, and the director. As this is a quality improvement project, informed consent is not required. Transparency will be maintained throughout each phase of implementation, along with proper leadership oversight. Overall, these considerations ensure an ethical implementation of the fall prevention project. Discussion Preventing falls to keep patients safe is a global problem (Morris et al., 2024). Many patient falls are preventable and occur due to a variety of factors, such as a lack of patient and staff education, and interventions in place not being personalized to the patient’s fall risk level (Twibell et al, 2023; Miles et al., 2025; Akhiwu et al., 2025; Agency for Healthcare Research and Quality, 2021). This MSN project seeks to reduce the patient fall rate on a local rehab unit by providing staff education to increase confidence in keeping patients safe, patient education, and implementing personalized interventions tailored to each patient based on their falls risk score. The sections that follow discuss evidence-based solutions for dissemination, the 19 significance of these solutions for advancing nursing practice, project strengths and limitations, and recommendations for moving forward. Evidence-Based Solutions for Dissemination This project will be shared as a poster presentation at Weber State University to peers and faculty in the MSN program. Beyond sharing it with college faculty, if the results prove significant, options for publication will be explored. Patient safety is an ongoing concern in hospitals; if successful, sharing this research project with as many people as possible through publication is essential. Upon project completion, the data will be compiled into a presentation to be shared at a meeting involving all hospital leaders and administration. The results from the pre- and postimplementation surveys, as well as the fall rate per 1000 patient days, will be shared. Once the data is shared and reviewed, a decision will be made on whether to implement this facility-wide, one unit at a time. As dissemination through the facility is considered, possible improvements to the program will also be discussed. Significance to the Advancement of Nursing Practice Patient falls are an ongoing issue for patients throughout the world, with many of them being preventable (Morris et al., 2024). Given the pronounced issue of falls, hospital staff must know how to keep patients safe and have the confidence to act. The Agency for Healthcare Research and Quality (n.d.) noted that fall prevention takes team effort, consistent communication, and personalized plans. This project implements training for the patient care team, patient education, and a multifactorial approach. Oftentimes, nurses respond to falls with a general approach or fail to address the root cause of a fall (Morris et al., 2024). This project equips nurses with the knowledge needed to 20 provide a personalized approach to fall prevention with each patient. It will strengthen their knowledge, which in turn will increase their confidence in keeping patients safe. Nurses can be held liable when a patient falls (South Carolina Nurses Association, 2024); arming them with adequate prevention skills can help protect not only patients but also nurses themselves. Implications One area of strength is its use of evidence-based fall prevention techniques. The Johns Hopkins Evidence-Based Practice Model for Nurses (JHEBP) was used as the framework for this project. Applying that model, research was conducted to identify and appraise the evidence (Bissett et al., 2025), which was then used to develop recommendations for the fall prevention project on the rehab unit. The JHEBP model encourages the ongoing evaluation of the project and communication of the outcomes (Gawlinski & Rutledge, 2008). A second strength is the assessment of staff confidence with pre- and postimplementation surveys. Similarly, data is collected throughout, and falls per 1000 patient days information is analyzed to assess the impact on the patient fall rate. A limitation of this project is that it does not account for staff who join the unit after project implementation has begun. As staff education is provided prior to the start of the program, any staff onboarding during the six-month implementation period will not have received the same education as the rest of the team. Incorporating fall training for new staff on the rehab unit into their orientation should be strongly considered. A second limitation is that patient buy-in may be difficult to obtain; they may not follow the guidelines or be unable to understand them due to their condition or injury. To address this limitation, patients with limited understanding should have fall-prevention education provided to their family members. Staff should also take extra precautions with those patients. 21 Lastly, AHRQ’s education is not tailored specifically to the facility. If facility-wide implementation is decided upon, it might be beneficial to tailor the education to the facility. Recommendations Upon successful completion of the pilot project, it is recommended that the fall prevention program be implemented across the hospital using a staggered, unit-by-unit approach. Phasing in the program one unit at a time allows for detailed monitoring and adjustments. Additionally, the staggered rollout will lead to long-term success and program sustainment. Continuous evaluation during the facility-wide implementation is essential to identify gaps, address challenges, and assess effectiveness at the unit level. The patient safety team, in collaboration with unit and department leaders, will oversee the rollout in each unit. During the pilot, pre- and post-implementation surveys were used to measure improvements in staff confidence. Unit leadership should conduct weekly check-ins with staff to obtain feedback, reinforce prevention education, and facilitate ongoing improvement efforts. For long-term sustainability, fall-prevention education should be incorporated into newemployee orientation for all staff. Likewise, prevention interventions should be officially incorporated into policy, whether by adding them to an existing policy or creating a new one. The policy should be reviewed yearly and updated as needed. Because new research on fall prevention continues to emerge, a literature review will be conducted annually to ensure continued adherence to evidence-based practice. The fall committee will be responsible for reviewing current literature and making updated recommendations as necessary. The responsibility to keep the program evidence-based through annual literature reviews will be included as a part of the committee’s defined roles. Conclusions 22 Despite attempts to prevent falls, they remain a frequent and preventable issue that costs patients and healthcare organizations millions and can have long-term negative effects (Morris et al., 2024). An exploration of the literature highlighted staff and patient education (Twibell et al, 2023; Miles et al., 2025; Akhiwu et al., 2025), a multifaceted approach, and more specifically, interventions tailored to the patient and their risk level (Agency for Healthcare Research and Quality, 2021), as proven ways to reduce the fall rate. Over 9 months, this fall prevention project will be implemented in a local hospital’s rehab unit, including staff and patient education, a preand post-implementation survey, and a fall TIPS sheet for nurses. This project highlights the importance of staff and patient education as well as patient-specific interventions in fall prevention programs. 23 References 12 Reasons Why Data is Important. The Council on Quality and Leadership. (2018, March 3). https://www.c-q-l.org/resources/guides/12-reasons-why-data-is-important/ Before-and-after study: Comparative studies. GOV.UK. (2020, January 30). https://www.gov.uk/guidance/before-and-after-study-comparativestudies#:~:text=A%20before%2Dand%2Dafter%20study%20(also%20called%20pre%2Dp ost%20study),a%20product%20or%20other%20intervention%2C%20and%20then Akhiwu, E. A., Brennan-Cook, J., Wright, Jr., C. D., & Cary, M. P. (2025). Evaluation of a Fall Prevention and Control Innovation. MEDSURG Nursing, 34(1), 39–43. https://doi.org/10.62116/msj.2025.34.1.39 Bissett, K., Ascenzi, J., Whalen, M., Dearholt, S. L., & Whahlen, M. (2025). Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals: Model & Guidelines. Sigma Theta Tau International. Branson, S. (July 29, 2025). Faculty Guide: Integrating the Johns Hopkins EBP Model into Nursing Education. American Association of Colleges of Nursing. https://www.aacnnursing.org/essentials/database/kit/i/ebp-model Durgan, H., & Aksoy, F. (2025). The Relationship Between Patients’ Perceptions of Illness and Their Satisfaction with Nursing Care. Journal of Education and Research in Nursing, 116– 122. https://doi.org/10.14744 Dusin, J., Melanson, A., & Mische Lawson, L. (2023, May). Evidence-Based Practice Models and Frameworks in the Healthcare Setting: A Scoping Review. ResearchGate. https://www.researchgate.net/publication/370961570_Evidencebased_practice_models_and_frameworks_in_the_healthcare_setting_a_scoping_review 24 Fall Tips: A Patient-Centered Fall Prevention Toolkit. Agency for Healthcare Research and Quality. (2021, February). https://www.ahrq.gov/patient-safety/settings/hospital/falltips/index.html Gawlinski, A., & Rutledge, D. (2008). Selecting a Model for Evidence-Based Practice Changes. AACN Advanced Critical Care, 19(3), 291–300. https://doi.org/10.4037/15597768-20083007 Heikkilä, A., Lehtonen, L., & Junttila, K. (2024). Consequences of Inpatient Falls in Acute Care: A Retrospective Register Study. Journal of Patient Safety, 20(5), 340–344. https://doi.org/10.1097/pts.0000000000001230 Hill, A.-M., Francis-Coad, J., Vaz, S., Morris, M. E., Flicker, L., Weselman, T., & Hang, J. A. (2024). Implementing falls prevention patient education in hospitals – older people’s views on barriers and enablers. BMC Nursing, 23(1). https://doi.org/10.1186/s12912-024-02289x How to use evaluation to improve patient care quality. Skills for Health. (April 17, 2025). https://www.skillsforhealth.org.uk/article/how-to-use-evaluation-to-improve-patient-carequality/ Jarden, R. J., Cherry, K., Sparham, E., Brockenshire, N., Nichols‐Boyd, M., Burgess, S., Grieve, K., Twomey, B., Walters, J., & Rickard, N. (2024). Inpatients’ experiences of Falls: A qualitative meta‐synthesis. Journal of Advanced Nursing, 81(1), 4–19. https://doi.org/10.1111/jan.16244 Khoja, A., & Moosa, L. (2023). Impact of Tailored Interventions for Patient Safety (TIPS) to Reduce Fall Rates. MedSurg Nursing, 32(2), 89–93. https://doi.org/https://research-ebscocom.hal.weber.edu/c/7nnlww/viewer/pdf/b2lfloawg5 25 Li, S., & Surineni, K. (2025). Falls in Hospitalized Patients and Preventive Strategies: A Narrative Review. The American Journal of Geriatric Psychiatry: Open Science, Education, and Practice, 5, 1–9. https://doi.org/10.1016/j.osep.2024.10.004 Mayorga, M., Gorospe, G., López, L., Jarquin, C., Seno, P., & Murphy, E. (2022). An Oncology Clinical Nurse Specialist-led Fall Prevention Program in an Outpatient Oncology/Hematopoietic Stem Cell Transplant Clinics and Infusion Setting Within an Academic Center Building a Culture of Fall Prevention. Oncology Nursing Forum, 49(2), 35–36. McKercher, J. P., Peiris, C. L., Hill, A.-M., Peterson, S., Thwaites, C., Fowler-Davis, S., & Morris, M. E. (2024). Hospital falls clinical practice guidelines: A global analysis and systematic review. Age and Ageing, 53(7). https://doi.org/10.1093/ageing/afae149 McLennan, C., Sherrington, C., Tilden, W., Jennings, M., Richards, B., Hill, A.-M., Fairbrother, G., Ling, F., Naganathan, V., & Haynes, A. (2024a). Considerations across multiple stakeholder groups when implementing fall prevention programs in the Acute Hospital Setting: A qualitative study. Age and Ageing, 53(10). https://doi.org/10.1093/ageing/afae208 McLennan, C., Sherrington, C., Tilden, W., Jennings, M., Richards, B., Hill, A.-M., Fairbrother, G., Ling, F., Naganathan, V., & Haynes, A. (2024). Considerations across multiple stakeholder groups when implementing fall prevention programs in the Acute Hospital Setting: A qualitative study. Age and Ageing, 53(10). https://doi.org/10.1093/ageing/afae208 26 Mikos, M., Banas, T., Czerw, A., Banas, B., Strzępek, Ł., & Curyło, M. (August 2, 2021). Hospital Inpatient Falls Across Clinical Departments. MDPI. https://www.mdpi.com/1660-4601/18/15/8167 Miles, K., Fotopoulos, R., Hutchinson, A. F., Khaw, D., & Hooper, S. (2025). Teach-back communication to decrease falls in inpatient rehabilitation settings: A mixed-methods study. Journal of the Australasian Rehabilitation Nurses’ Association, 27(2), 23–32. https://doi.org/10.33235/jarna.27.2.23-32 Montero-Odasso, M., van der Velde, N., Martin, F. C., Petrovic, M., Tan, M. P., Ryg, J., Aguilar-Navarro, S., Alexander, N. B., Becker, C., Blain, H., Bourke, R., Cameron, I. D., Camicioli, R., Clemson, L., Close, J., Delbaere, K., Duan, L., Duque, G., Dyer, S. M., … Masud, T. (2022b, September 2). World Guidelines for Falls Prevention and Management for Older Adults: A Global Initiative. Age and Ageing. https://pmc.ncbi.nlm.nih.gov/articles/PMC9523684/ Morris, M. E., Thwaites, C., Lui, R., McPhail, S. M., Haines, T., Kiegaldie, D., Heng, H., Shaw, L., Hammond, S., McKercher, J. P., Knight, M., Carey, L. M., Gray, R., Shorr, R., & Hill, A.-M. (2024). Preventing hospital falls: Feasibility of care workforce redesign to o26ptimize patient falls education. Age and Ageing, 53(1), 1–9. https://doi.org/10.1093/ageing/afad250 Rogers, S., Haddad, Y. K., Legha, J. K., Stannard, D., Auerbach, A., & Eckstrom, E. (2021). CDC STEADI : Best Practices for Developing an Inpatient Program to Prevent Older Adult Falls After Discharge. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/108535 27 Seppala, L. J., Kamkar, N., Poelgeest, E. P. van, Thomsen, K., Daams, J. G., Ryg, J., Masud, T., Montero-Odasso, M., Hartikainen, S., Petrovic, M., van der Velde, N., & Adults, the T. F. on G. G. for F. in O. (2022). Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age & Ageing, 51(9), 1–12. https://doi-org.hal.weber.edu/10.1093/ageing/afac191 South Carolina Nurse. (2024, December). Nurse Case Study: Failure to monitor high fall risk patient; failure to educate family on fall prevention. South Carolina Nurse. https://researchebsco.com.hal.weber.edu/c/7nnlww/search/details/kktqi6qjt5?db=ccm&limiters=DT1%3A 2020-07-22%2F2025-07-22%2CRV%3AY%2CFT%3AY&q=patient%20falls Twibell, K. R., Delaney, L., Siela, D., Coers, G., Davis, C., Drown, C., Kring, K., Duncan, J., & Jones, J. A. (2023). Tailoring fall prevention videos for medical-surgical inpatients: A randomized controlled trial. MedSurg Nursing, 32(3), 170-178. Weller, J. M., Mahajan, R., Fahey-Williams, K., & Webster, C. S. (2024). Teamwork matters: Team situation awareness to build high-performing healthcare teams, a narrative review. British Journal of Anaesthesia, 132(4), 771–778. https://doi.org/10.1016/j.bja.2023.12.035 28 Appendix A Data Collection Spreadsheet https://docs.google.com/spreadsheets/d/1w9OKSb5fNyuhpuvZwcR_lfN2kuly3n_p_ayMTmopcY/edit?usp=sharing 29 Appendix B Patient Education * Fall TIPS Collaborative. (n.d.). Fall TIPS information sheet for patients: Paper and electronic. https://www.falltips.org/wp-content/uploads/2018/04/5a.-Fall-TIPS-Information-Sheet-forPatients-PAPERand-ELECTRONIC.pdf This is an open-access document available to the public via the Agency for Healthcare Research and Quality’s Fall TIPS program. 30 Appendix C Fall Champion Training • https://www.falltips.org/wp-content/uploads/2019/12/Fall-TIPSTraining_Collaborative_final.pdf 31 Appendix D Staff Training • https://www.falltips.org/wp-content/uploads/2020/12/Evaluation-of-a-PatientCentered-Fall-Prevention-Toolkit12012020.pdf • https://www.youtube.com/watch?v=_ebs6sK-k5w 32 Appendix E Nurse Fall Tip Sheets 33 * Fall TIPS Collaborative. (n.d.). Fall TIPS common misconceptions: Assessment/Planning. https://www.falltips.org/wp-content/uploads/2018/05/4.-Fall-TIPS-CommonMisconceptions_AssessmentPlanning.pdf These are open-access documents available to the public via the Agency for Healthcare Research and Quality’s Fall TIPS program. 34 Appendix F Pre-Implementation Survey On a scale from 1-5, 1-extremely low confidence, 2-low confidence, 3-moderate confidence, 4high confidence, 5-extremely confident, please rate yourself on the following questions: 1. How confident are you in identifying patient risk factors for falls? __________________ 2. How confident do you feel in assessing a patient’s fall risk? _______________________ 3. How confident are you in placing appropriate fall prevention interventions based upon the patient’s fall risk score? ______________________________________________ 4. How confident do you feel documenting fall prevention interventions? _____________ 5. How confident do you feel in providing fall risk education to patients? _____________ 6. How confident do you feel about including family members in a patient’s fall prevention plan? ____________________________________________________________ 7. How confident are you in re-evaluating the patient’s fall risk when there is a clinical change? ________________________________________________________________ 8. How confident are you in escalating concerns related to a patient’s fall risk? _______ 9. How confident are you in responding to a patient who has fallen? _________________ 10. How confident are you in completing the required documentation after the fall? _______ Total Score: _______________ Short answer questions: What aspects of fall prevention do you have concerns about or that you would like to learn more about? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are there any tools or training that would help you become more confident in preventing and addressing patient falls? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 35 Appendix G Fall Knowledge Test Fall Knowledge Test Each question may have more than one correct answer. Please circle the letters that correspond to the correct answers. 1. Which of the following statements is correct? a. Falls have a multifactorial etiology, so fall prevention programs should comprise multifaceted interventions. b. Regular medication reviews can help prevent patient falls. c. The risk of falling will be lessened when a patient’s toileting needs are met. d. The use of antipsychotic medications is associated with an increased risk of falls in older adults. 2. A multifaceted intervention program should include: a. b. c. d. Individually tailored fall prevention strategies Education to patients/family and health care workers Environmental safety Safe patient handling 3. Risk factors for falls in the acute hospital include all the following except: a. b. c. d. Dizziness/vertigo Previous fall history Antibiotic usage Impaired mobility from stroke disease 4. Which of the following statements is true? a. The cause of a fall is often an interaction between the patient’s risk, the environment, and the patient's risk behavior. b. An increase in hazardous environments increases the risk of falls. c. The use of a patient identifier (e.g., an identification bracelet) helps staff identify patients at risk for falls. d. A fall risk assessment should include a review of fall history, mobility issues, medications, mental status, continence, and other patient risks. 5. Patients with impaired mobility should be: a. b. c. d. Confined to bed Encouraged to mobilize with assistance Assisted with transfers Referred for exercise program or prescription of walking aids as appropriate 36 6. The management of the acutely confused patient should include all the following except: a. b. c. d. Moving patients away from the nursing station Involving family members to sit with the patient Orienting patients to the hospital environment Reinforcing activity limits to patients and their families 7. Which of the following statements is false? a. b. c. d. Fall prevention efforts are solely the nurses’ responsibility. A patient taking 4 or more oral medications is at risk of falling. A patient who is taking psychotropic medication is at a higher risk of falling. Testing or treatment for osteoporosis should be considered in patients who are at high risk for falls and fractures. 8. In hospital settings, intervention programs should include: a. b. c. d. Staff education on fall precautions Provision and maintenance of mobility aids Post fall analysis and problem-solving strategy Bed alarms for all patients, regardless of risk 9. When assessing patients, which of the following statements is false? a. All patients should be assessed for fall risk factors at admission, at a change in status, after a fall, and at regular intervals. b. Medication review should be included in the assessment. c. All patients should have their activities of daily living and mobility assessed. d. Environmental assessment is not important in the hospital as it is all standardized. 10. Risk factors for falls include: a. b. c. d. Parkinson’s disease Incontinence Previous history of falls Delirium 11. Exercise programs for ambulatory older adults should: a. b. c. d. Be very aggressive Be unsupervised Be ongoing Include individualized strength and balance training 37 12. a. b. c. d. Which of the following statements on education in fall prevention is false? Education programs should primarily target health care providers, patients, and caregivers. Staff education programs should include the importance of fall prevention, risk factors for falls, strategies to reduce falls, and transfer techniques. Instruction on safe mobility, with emphasis on high-risk patients, should be provided to both patients and families. Education should be provided only at the start of the fall prevention program. 13. Which of the following is recommended to improve patient safety? a. Locking wheeled furniture when it is stationary. b. Having nonslip flooring. c. Placing frequently used items (including call bell, telephone, and remote control) within reach of the patient d. Rounding hourly to address patient needs Answer Key: 1. A, B, C, D 2. A, B, C, D 3. C 4. A, B, C, D 5. B, C, D 6. A 7. A 8. A, B, C 9. D 10. A, B, C, D 11. C, D 12. D 13. A, B, C, D *Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ Publication No. 13-0015-EF). https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit_0.pdf This is an open-access document available to the public via the Agency for Healthcare Research and Quality’s Fall TIPS program. 38 Appendix H Post-Implementation Survey On a scale from 1-5, 1-extremely low confidence, 2-low confidence, 3-moderate confidence, 4high confidence, 5-extremely confident, please rate yourself on the following questions: 1. How confident are you in identifying patient risk factors for falls? __________________ 2. How confident do you feel in assessing a patient’s fall risk? _______________________ 3. How confident are you in placing appropriate fall prevention interventions based upon the patient’s fall risk score? _______________________________________________ 4. How confident do you feel documenting fall prevention interventions? _____________ 5. How confident do you feel in providing fall risk education to patients? _____________ 6. How confident do you feel about including family members in a patient’s fall prevention plan? ______________________________________________________________ 7. How confident are you in re-evaluating the patient’s fall risk when there is a clinical change? ________________________________________________________________ 8. How confident are you in escalating concerns related to a patient’s fall risk? _______ 9. How confident are you in responding to a patient who has fallen? _________________ 10. How confident are you in completing the required documentation after the fall? _______ Total Score: _______________ Short answer questions: What aspects of fall prevention implementation did you learn the most from? What would you like to see done differently? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ How has the fall prevention education and multifactorial approach changed your practice or your approach to patient falls? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 39 Appendix I Timeline Project Start Month 1 Month 2 Months 3-9 • Present project to stakeholders and obtain buy-in. • Work with unit leaders to select fall champtions. • Discuss research findings and recommendations for fall prevention. • Collaborate with leaders to establish implementation plan. • Pre-implementation survey and fall knowledge test to be taken by staff. • Fall chamption and staff training sessions. • Implementation of fall prevention pilot program on the rehab unit. • Continuous evaluation at weekly falls committee meetings. Project Completion • Staff will take the postimplementation survey. Results from the pre- and postsurveys will be compared. • Fall rate per 1000 patient days will be assessed for the past 6 months. • Administration and leadership will discuss the appropriateness of the pilot for hospital wide dissemination.