Graduation Year
2015
Degree Type
Open Access Capstone
Document Type
Capstone
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
Department Name when Degree Awarded
Baccalaureate and Graduate Nursing
First Advisor
Catherine Lynn Velotta
Department Affiliation
Nursing
Second Advisor
Mary DeLetter
Department Affiliation
Nursing
Third Advisor
Gina L. Purdue
Department Affiliation
Nursing
Abstract
In-patient falls are common but preventable adverse events. A patient fall has become a targeted event that hospitals across the country are trying to prevent by implementing new evidence-based strategies and techniques. The purpose of this capstone project was to implement a valid and reliable fall risk assessment tool and a post-fall huddle process. Following a 30-day pilot of the new fall prevention protocol on a medical-surgical unit at the Cabell Huntington Hospital, the documentation of fall risk and post-fall huddles was examined. Fall rates during the pilot were compared to pre-implementation rates. During this project, the new fall risk assessment tool, the Morse Fall Scale (MFS), was completed for all patients. The required completion of the MFS form, integrated into the computer charting system, facilitates adherence to the fall prevention protocol. However, the completion of the online training module and competency test was low at 20.5%. Lack of training may compromise the effective use of the tool. The staff’s accurate use of the MFS needs to be monitored closely and feedback provided to ensure effectiveness of this tool. The total number of patient falls during the 30-day pilot was five. This was a 29% improvement over the last reported month (n=7). Post-fall-huddles were conducted and documented for all five fall events. Ongoing monitoring of subsequent interventions implemented by the staff to prevent falls and frequent dissemination of unit-specific fall data is needed to ensure fidelity to the protocol. More information is needed on the context of falls to evaluate patient safety practice.
Copyright
2015 Ashlee D. Gallion
Recommended Citation
Gallion, Ashlee D., "Improving a Fall Prevention and Management Program in an Acute Care Setting" (2015). Doctor of Nursing Practice Projects. 7.
https://encompass.eku.edu/dnpcapstones/7
