Graduation Year


Degree Type

Open Access Capstone

Document Type


Degree Name

Doctor of Nursing Practice (DNP)



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Baccalaureate and Graduate Nursing

First Advisor

Catherine Lynn Velotta

Department Affiliation

Baccalaureate and Graduate Nursing

Second Advisor

Mary DeLetter

Department Affiliation

Baccalaureate and Graduate Nursing

Third Advisor

Gina L. Purdue

Department Affiliation

Baccalaureate and Graduate Nursing


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.

Included in

Nursing Commons