Date of Award

Summer 2024

Project Type

Thesis

College or School

CHHS

Department

Nursing

Program or Major

Direct Entry Master's of Nursing

Degree Name

Master of Science

First Advisor

Pamella Kallmerten

Second Advisor

Deborah Simonton

Abstract

Introduction At a nonprofit hospital located in New Hampshire, a thorough 5P Assessment was executed to identify the root cause behind an increase in falls occurring on a medical-surgical floor. Subsequently, a comprehensive quality improvement initiative was launched with the dual goals of minimizing falls and enhancing patients' awareness regarding their susceptibility to experiencing a fall during their length of stay. Patient falls are the most common adverse events reported in hospitals and are considered a sentinel event (LeLaurin & Shorr, 2019). Hospitals need to adopt a multifaceted approach to minimize the risk of patients experiencing falls during their inpatient stay. A crucial aspect of this effort involves prioritizing patient education in fall prevention strategies.

Methods Utilizing the FADE Model (Focus, Analyze, Develop, Execute), registered nurses and licensed nursing assistants engaged in a three-week quality improvement project. This initiative involved conducting pre- and post-intervention surveys through Qualtrics, focusing on identifying the reduction of risky patient behaviors and improving patient awareness of their susceptibility to falls during hospitalization.

Intervention An educational pamphlet about who is at an increased risk for a fall, was given to patients within 24 hours of admissions onto the unit. The pamphlet outlined the dangers of experiencing a fall, who is at an increased risk of experiencing a fall and ways patients can take initiative to prevent falls.

Results While the results of this quality improvement project did not achieve statistical significance, they uncovered valuable insights into additional obstacles. Initiating a second FADE cycle would be beneficial, allowing for further refinement of strategies and potentially enhancing outcomes.

Conclusion An educational patient pamphlet about falls and the dangers associated with experiencing a fall while hospitalized is a good resource to increase patient safety and knowledge.

Keywords patient education, fall reduction, educational pamphlets, risky behaviors, quality improvement, evidence-based guidelines, 5P assessment

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