Reducing Falls in the Acute Care Setting: A Quality Improvement Project

Author Biographical Info

Elorm Miriam Adzokpa, BSN, RN, is a Doctor of Nursing Practice Family Nurse Practitioner student at the University of Texas Health Science Center at Houston Cizik School of Nursing. She has nearly 12 years of nursing experience across nursing home care, pediatric home health, orthopedic and trauma acute care, and intensive care settings. Her clinical interests include patient safety, fall prevention, and implementation of evidence based strategies to improve outcomes in hospitalized patients. Her DNP quality improvement project evaluated the use of a 5P visual aid to strengthen fall prevention practices on an orthopedic and trauma unit in an acute care setting.

Date of Doctor of Nursing Practice Project Completion

Fall 12-2-2025

Faculty Advisor

Dr. Susan Stafford

Abstract

Falls remain one of the most common adverse events in acute care settings and are associated with increased morbidity, extended hospital stays, and higher healthcare costs. Orthopedic and trauma patients are particularly vulnerable due to mobility limitations, postoperative recovery, and complex medical conditions. The purpose of this quality improvement project was to reduce inpatient falls on an adult orthopedic and trauma unit by implementing a visual aid to reinforce the 5P fall-prevention framework. A pre–post quality improvement design was used during an eight-week implementation period. The intervention included a standardized fall prevention bundle that reinforced existing Fall TIPS board use and electronic medical record fall-prevention protocols while introducing two new components: a visual cue based on the 5Ps (pain, potty, position, possessions, and pathway) placed in patient rooms and targeted staff education delivered during unit huddles. Outcome and process measures included fall rates per 1,000 patient-days, fall-related injury severity, and staff adherence to fall-prevention practices. Descriptive statistics and run charts were used to evaluate trends in process reliability and fall outcomes. No patient falls were recorded during the implementation period. Improvements were observed in visual aid utilization, staff situational awareness, and family engagement in fall-prevention communication, while environmental safety practices remained consistently strong. These findings suggest that integrating visual cues with staff education may strengthen fall-prevention practices and support safer inpatient environments. Continued reinforcement of documentation practices and interdisciplinary engagement may enhance the sustainability of fall-prevention initiatives.

Keywords

fall prevention, patient safety, quality improvement

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