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

Dr. Gina Purdue, DNP, RN, CNE

Department Affiliation

Baccalaureate and Graduate Nursing

Second Advisor

Dr. Fontaine Sands, DrPH, MSN, RN, CIC

Department Affiliation

Baccalaureate and Graduate Nursing

Department Affiliation

Baccalaureate and Graduate Nursing


Patient falls during hospitalization are a major clinical problem that occurs frequently. It is estimated that between 700,000 and 1,000,000 patients fall in hospitals each year. Between 30% and 50% of patients who fall in hospitals are injured. Consequently, falls with serious injury are among the most frequent hospital-reported sentinel events. Hospitals also suffer from patient falls as the Centers for Medicare and Medicaid Services no longer reimburse for costs related to preventable falls or fall-related injuries. Given the significant negative impact of falls on patients and healthcare organizations, hospitals continue to look for interventions to decrease falls. Research strongly supports patient-directed visual cues, frequently recognized signs, and symbols as an evidence-based intervention to reduce patient falls during hospitalization. The purpose of this quality improvement project was to pilot "Call! Don't Fall" ceiling tiles installed above patients' beds that served as a visual cue, safety warning, and constant reminder for patients to call for assistance to help decrease falls. To evaluate the impact of this project, both outcome and process objectives were measured. Results indicated that the fall rates decreased when the baseline was the same timeframe in consecutive calendar years. Fall rates did not decrease when the baseline was three months before the project was implemented. The total number of calls that patients initiated with the nurse call light decreased from the baseline. Further, caregivers' knowledge of using patient-directed visual cues improved after completing the ceiling tile education. The results also indicated that caregivers had a high level of self-efficacy in preventing hospitalized patients from falling. Furthermore, the leadership team rated the overall execution of this project as excellent.

IRB Approval Number (if applicable)


Included in

Nursing Commons