Date of Doctor of Nursing Practice Project Completion

Fall 12-1-2027

Abstract

Purpose

This quality improvement project aimed to decrease patient falls by 25% from baseline within three months of implementing an escape room simulation-based fall-prevention training program for registered nurses (RNs) and mental health technicians (MHTs).

Background

The project was implemented in a 23-bed adult inpatient psychiatric unit within a teaching hospital in the Southwest region of the United States.

Methodology

The Plan-Do-Study-Act (PDSA) framework guided the implementation of an escape room-style fall-prevention simulation. A total of 70 staff members, consisting of nurses and MHTs, participated in a 15-minute simulation to identify fall hazards in a staged patient room using the “5 Ps” (Pain, Potty, Position, Possessions, Pump).

Results

The mean monthly baseline fall rate was 3.93 per 1,000 patient-days.  Post-intervention, the fall rate decreased to 2.13 per 1,000 patient-days, exceeding the 25% reduction target.  RN and MHT knowledge increased from 87.2% baseline to 95.71% after the fall prevention training.

Implications

The simulation-based escape room improved staff knowledge and was linked to reduced fall rates in the inpatient psychiatric unit, addressing a key safety concern. These findings suggest that interactive simulation training can boost staff preparedness and help prevent falls in behavioral health settings. Limitations include the short evaluation and single-unit focus. Future efforts could expand training to more units and assess long-term reductions in falls.

Keywords

Fall prevention, simulation-based education, psychiatric inpatient care, patient safety, quality

Share

COinS
 
 

To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.