Date of Award

Summer 2025

Project Type

Thesis

College or School

CHHS

Department

Nursing

Departments (Collect)

Department of Nursing

Program or Major

Masters of Science, Nursing

Degree Name

Other

First Advisor

Deborah Simonton EdD, MS, RN, CNL

Second Advisor

Pamela S. Kallmerten PhD, DNP, RN, CNL

Abstract

Abstract

Background: Inpatient falls remain a significant concern for orthopedic units, especially among elderly post-surgical patients. Despite existing protocols, fall incidents persist due to various modifiable and non-modifiable risk factors. Nursing staff play a critical role in fall prevention, and targeted education is essential to reinforce best practices.

Local Problem: The orthopedic microsystem reported 13 falls during the 2023–2024 fiscal year, with contributing factors including post-operative weakness, patient confusion, and inconsistent communication. Staff surveys revealed gaps in education, awareness, and communication related to fall incidents.

Methods: A quality improvement initiative using the Define, Measure, Analyze, Improve, Control (DMAIC) model was implemented, featuring a unit-specific educational poster with fall prevention reminders, unit data, and a real-time Situation, Background, Assessment, Recommendation (SBAR) section summarizing recent fall incidents. Pre- and post-intervention surveys measured changes in staff knowledge, communication practices, and perceived preparedness.

Results: Sixteen staff completed the pre-survey, and twelve completed the post-survey. After the intervention, 92% of staff noticed the poster, 73% reported increased awareness of fall events, and 64% noted improved communication due to the SBAR section. While no staff members reported feeling more prepared to prevent falls, qualitative feedback indicated an enhanced situational awareness and a cultural shift toward fall prevention.

Conclusion: This low-cost, nurse-driven intervention improved staff communication and awareness around fall incidents. Embedding real-time, unit-specific data into an educational tool promoted engagement and reflection. The project highlights the value of context-specific nursing education and supports the potential for broader application across inpatient units.

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