Date of Award

Fall 2026

Abstract

BACKGROUND: Patient falls are a significant concern for patient safety in the acute care setting and are typically connected to inadequate communication during shift transitions. Bedside shift report is considered the standard of care, however, barriers are still present when shifting patient care responsibilities among nursing staff. A literature review identified standardized safety huddles as an evidence-based practice to improve areas of communication, teamwork, situational awareness, and patient safety. This quality improvement (QI) project concentrated on the implementation of a standardized evening safety huddle in order to improve nursing communication and reduce patient falls on an inpatient medical-surgical/telemetry unit. METHODS: The Plan, Do, Study, Act (PDSA) cycle was utilized to guide the quality improvement process. Pre and post-intervention surveys of nursing staff on the unit were conducted for the purpose of measuring perceptions of communication and patient safety. Audits were performed to evaluate huddle compliance and patient fall data was obtained to assess project outcomes. INTERVENTION: Prior to the start of each night shift, a structured evening safety huddle was conducted and led by the charge nurse. Nursing staff were educated on the purpose of the intervention, the relationship between communication and patient safety, and the template for the huddle process. Huddles highlighted high fall risk patients, pressure injury risks, telemetry monitoring, admissions, discharges, and other patient safety concerns. RESULTS: The project aimed for 75% huddle compliance, which was nearly missed with safety huddles documented on 21 of 29 implementation days, resulting in a 72% compliance rate. After implementation, positive staff perceptions of communication and patient safety on the unit improved by an average of 13.8%. One patient fall was recorded on the unit during this timeframe, ultimately yielding an average monthly fall rate of 1.0 fall per month. This surpassed the original goal of reducing patient falls from 2.4 to 1.5 falls per month. CONCLUSIONS: Implementing a standardized evening safety huddle was a cost effective and feasible intervention that improved staff perceptions and exceeded the patient fall reduction goal. This intervention portrayed strong unit buy-in and was successfully integrated into existing staff workflow. Continued use over a longer time period may further improve communication, safety culture, and patient fall rates.

Document Type

Master's Thesis

First Advisor

April Phelps

Second Advisor

Melanie Davis

College or School

CHHS

Department or Program

School of Nursing

Degree Name

Master of Science

Included in

Other Nursing Commons

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