Date of Doctor of Nursing Practice Project Completion

Spring 2026

Faculty Advisor

Dr. Marie McBee

Abstract

The purpose of this scholarly project was to implement a multifactorial fall prevention program within a medical-surgical psychiatric unit. The program was intended to reduce the incidence of falls, strengthen staff compliance, and bridge the gap of fall education. The interventions were developed based on evidence-based fall prevention strategies. The project was implemented within a large healthcare organization in the Texas Medical Center (TMC) located in Houston, Texas. The project utilized the Plan-Do-Study-Act (PDSA) framework. Staff were given education prior to implementation and reeducation during the project cycle. Visual guides were created to guide staff and assist with documentation expectations. Weekly electronic medical record chart audits were done to review hourly rounding compliance and viewing of a fall education video for patients. The number of falls decreased in relation to the number of falls that occurred during the same timeframe the year before. The hourly rounding average was well above the required value at 4.42. The hourly rounding average in Week 3, which was the first week of data collections was 3.72 and in Week 12 it was 5.21. The findings suggest that the multifactorial fall prevention program assisted in the decline of falls and increased fall prevention education. Reducing the incidence of patient falls helps to alleviate patient harm, prevent longer hospital stays, and extra expenses. The project showed that a multifactorial  fall prevention program improves safety and increases staff awareness. Integrating hourly rounding, patient education, and environmental safety checks into routine practice may encourage sustainable fall prevention endeavors.                                                                                                                              

Keywords

fall prevention, fall education, multifactorial, hourly rounding, 5 Ps

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