Document Type
DNP Project
Department
School of Nursing
Date of Degree
Spring 2025
Degree
Doctor of Nursing Practice (DNP)
Primary Advisor
Dr. Cara Pandovano
Keywords
Patient Safety; Fall Tailoring Interventions for Patient Safety Tool; Quality Improvement
Abstract
Background: Falls among hospitalized patients pose a significant risk to patient safety, leading to increased morbidity, extended hospital stays, and higher healthcare costs. Despite existing fall prevention strategies, compliance with evidence-based interventions remains inconsistent. The Fall Tailoring Interventions for Patient Safety (Fall TIPS) tool is a structured, evidence-based approach designed to reduce fall rates through improved risk assessment and patient-specific interventions. This quality improvement project was implemented in a medical-surgical unit to improve staff knowledge, increase compliance with fall prevention documentation, and reduce overall fall rates.
Aims/Objectives: This project aimed to assess the impact of implementing the Fall TIPS tool on patient fall rates, staff compliance with fall prevention documentation, and staff knowledge of fall prevention strategies. The primary objectives included evaluating changes in fall rates before and after implementation, tracking trends in staff compliance with Fall TIPS documentation, and determining whether staff education led to a measurable improvement in fall prevention knowledge.
Methods: This quality improvement project was conducted in a medical-surgical unit with staff education provided through an informational poster on the Fall TIPS tool. A total of 35 staff members reviewed and signed off on the educational material. Post-implementation, 25 staff members completed a survey assessing knowledge retention. Fall rates were monitored pre- and post-intervention over 12 months, and staff compliance with Fall TIPS documentation was tracked bi-weekly. A chi-square test was conducted to analyze differences in fall rates before and after implementation. Compliance trends were evaluated using descriptive statistics, and a paired t-test was used to assess changes in staff knowledge.
Results: Following the implementation of the Fall TIPS tool, the average number of falls per month decreased from 2.8 falls pre-implementation to 2 falls post-implementation. Although a downward trend was observed, statistical significance could not be determined due to the small sample size. Staff compliance with Fall TIPS documentation declined over time, with completion rates dropping from 30 documented sheets in the first week to only 8 in the final week of monitoring. Despite challenges in sustaining compliance, staff knowledge of fall prevention strategies significantly improved post-training, as demonstrated by a statistically significant result from the paired t-test (p < 0.05).
Conclusions/Recommendations: The implementation of the Fall TIPS tool contributed to a modest reduction in fall rates and a significant improvement in staff knowledge. However, maintaining compliance with fall risk documentation remained a challenge. To sustain the benefits of this intervention, future efforts should focus on continuous staff engagement, periodic training reinforcement, and stronger accountability measures for documentation compliance. Additionally, integrating Fall TIPS into the electronic medical record system may enhance ease of documentation and tracking, ensuring long-term adherence to fall prevention protocols and improving patient safety outcomes.
Copyright Notice
©2025 Alexa Belfonte. All rights reserved.
Recommended Citation
Belfonte, A. (2025). Enhancing Patient Safety Through the Implementation of the Fall TIPS Assessment Tool: A Nurse-Led Quality Improvement Initiative. , (). Retrieved from https://hsrc.himmelfarb.gwu.edu/son_dnp/181
Open Access
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