Date of Doctor of Nursing Practice Project Completion

Summer 8-7-2026

Faculty Advisor

Dr. Francine Snow

Abstract

Fall Reduction Among Adults on a Medical Unit Using the Tailoring Intervention for Patient Safety (TIPS) Sheet

Purpose: This quality improvement project was intended to decrease the average unit falls by 80% from baseline by implementing the Tailoring Intervention for Patient Safety (TIPS) Sheet.

Background: The project was implemented on an adult medical unit at a large suburban hospital in Houston, Texas. The leadership goal was that the average raw number of falls each month would be no more than 2, but the current monthly average was 2.5.The total baseline number of falls on the unit in the past 12 months was 30.

Methodology: Unit staff educated patients using the fall TIPS sheet to develop a tailored fall prevention plan with the patient, engaging them in this plan of care urging they ask for help when getting out of bed.

Results: Of 15 audits of staff practice and patient knowledge rated in the same audit, only 2 passed (with all indicators passing) for an overall performance rate 13.33%.

However, patient knowledge was rated consistently higher than indicators on staff physical use of the form. The project's goal of achieving an 80% reduction in the average number of falls from 2.5 per month to 2 per month was achieved. The annualized number of falls is anticipated to be zero.

Implications: Ensure unlicensed assistive personnel understand their value in the project. Managers are key to setting expectations for staff performance in fall prevention.

Although staff performance indicated poor compliance in use of the TIPS sheet, the audit of patient understanding of their role in fall prevention was more promising. And the actual number of falls was zero through the data collection period.

Keywords

Fall Reduction, Fall Prevention, Adults, Medical Unit, Inpatient, Hospital, Tailoring Intervention for Patient Safety (TIPS) Sheet, DNP Quality Improvement Project

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