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Problem Statement

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Problem Statement

Need Statement

Patient falls are a relevant patient safety and quality improvement issue in acute care hospitals. Patients admitted to hospitals may have a higher risk of falls due to acute illness, new environment, limited mobility, weakened strength, cognitive changes, medication effects, and requiring assistance to perform activities like going to the bathroom and walking. The Agency for Healthcare Research and Quality (AHRQ, 2021) describe patient falls as a key patient safety issue that might cause injuries, increase healthcare consumption, prolong hospitalization, and incur additional costs. Thus, preventing patient falls is an important area of nursing quality improvement. The suggested project is aimed at achieving more consistent fall prevention interventions via a standardized, nurse-led fall prevention education and intervention bundle. The PICOT question is: In adult hospitalized patients identified as being at risk for falls (P), how does the implementation of a standardized, nurse-led fall prevention education and intervention bundle (I) compared with current fall prevention practices (C) impact the occurrence of patient falls (O) within 4 weeks (T)? This quality improvement issue is suitable for a nurse-led initiative since nurses conduct fall risk assessment, educate patients and their families, implement safety interventions, report changes in patients' condition, and monitor results.

Population and Setting

The population is hospitalized adult patients who are determined to be at high risk of falls. The setting will be the acute care medical-surgical hospital unit. This population is appropriate because hospitalization puts a patient at risk for falls due to change in physical functioning, medication use, cognitive status, mobility, and unfamiliarity with the environment. Vulnerable populations are older adults, weak, immobile, confused, or acutely ill patients. According to the CDC (2025), it is recommended to incorporate systematic fall risk assessment and fall prevention strategies into inpatient care for older adults.

This setting is also appropriate because nurses can frequently assess risk and carry out fall-prevention activities. Fall prevention involves coordinated effort of nurses, physicians, pharmacists, physical and occupational therapists, patients, and families. According to Schoberer et al. (2022), multifactorial interventions, education, and counseling are important elements of fall prevention. Hence, standardized intervention in the acute care hospital can ensure consistency and promote patient-centeredness and interprofessional collaboration.

Overview of Intervention

The suggested intervention is the package of fall-prevention education and intervention, carried out by nurses using standardized protocol. In accordance with the protocol, nurses should conduct fall-risk assessment of admitted patients at admission and in case the condition of patients’ changes. Individual fall-prevention interventions should be developed for patients and their families with fall risks, including the education about fall risk, the proper usage of the call button, the safe walking, suitable footwear, and asking for help before getting up from bed. Environmental interventions will consist of keeping the call button and personal things within the reach of patients, having enough lighting, eliminating environmental barriers, proper bed positioning, and helping with mobilization and toileting.

Also, in order to provide proper nursing intervention and avoid adverse events, nurses will make standardized documentation and communication of patients' fall-prevention plans during nursing handovers. This intervention follows the recommendations provided by AHRQ Fall TIPS model, which includes assessment, individualized fall-prevention planning, and consistent implementation. The implementation of Fall TIPS toolkit was related to lower numbers of total and injurious falls among inpatients (Dykes et al., 2020). The suggested intervention is suitable for the target population because it can be individualized considering the characteristics and risks of patients. Also, it is suitable for the hospital because nurses can incorporate it into their usual practices.

Comparison of Approaches

The comparison will be on the existing or conventional fall prevention strategies. Conventional strategies might include fall-risk assessment done at hospitals, regular education and identification of patients with risks of falling and signs and interventions based on nurses' decisions. Even if the conventional strategies might help prevent the risks, inconsistencies in their implementation might reduce their effectiveness. Standardized bundle is more consistent and clearly defined in terms of expectations from nurses.

Another important alternative would be a multifactorial fall prevention strategy with an involvement of several professionals. Such a strategy might involve nurses, doctors, pharmacists, physical and occupational therapists and others. Pharmacists would identify medications increasing risk of falls, physical therapists would assess patient's mobility, occupational therapists would focus on patients' functionality and environment, doctors would check whether there are any medical problems causing patients to fall. This strategy would be more complete in assessing patients' risks of falls than a nurse-led strategy.

This strategy might require more personnel and time to coordinate actions and implement. Since this project lasts for four weeks, it is possible to conduct only a nurse-led bundle and ask for interprofessional support for difficult cases.

Outcome Draft

The major outcome is going to be a decrease in the number of patients' falls within the target population over the four-week implementation period compared with current fall prevention interventions. Falls can be assessed through the hospital incident reporting program and calculated on falls per 1,000 patient-days, when applicable. One more process measure will be a percentage of patients who were provided with fall prevention education and a standardized bundle. The intended outcome is to prove that systematic nursing education and individual interventions lead to improved patient safety and decreased preventable falls. Having an outcome measure allows developing a framework to decide about the improvement of quality and safety as well as expansion of the intervention.

Time Estimate

Development and implementation of the intervention can take about four weeks. In week one, project leader will study current fall prevention practices, analyze baseline fall rates, get stakeholder comments and develop educational materials and intervention checklists. During week two, nurses will be trained on how to implement a standardized bundle, document interventions and educate patients. The intervention will be implemented in weeks three and four. Fall incidents, bundle implementation and patient education will be assessed during implementation. At the end of week four, outcome data will be compared with baseline data.

It is realistic time frame since the intervention relies on existing nursing responsibilities and does not imply development of new technology. Barriers to implementation can include staffing issues, other competing priorities, inconsistent implementation, non-compliance with documentation requirements, short stays and inability of patients to understand the education. Leadership support, concise education, standard documentation and feedback can help to overcome these barriers.

Literature Review

There is substantial scientific evidence supporting the use of standardized fall-prevention programs for adult patients in hospitals. According to AHRQ (2021), inpatient falls are one of the major patient safety issues, and there is scientific evidence available for hospitals to use. The Fall TIPS model can be used since it includes standardized assessment, patient-specific intervention, family involvement, and communication among healthcare professionals. Dykes et al. (2020) prove that the use of such patient-centered approach leads to a decrease in falls as well as injurious falls.

Education can be another aspect of the project to be considered. As indicated by Morris et al. (2022) in their systematic review and meta-analysis of the evidence about hospital fall-prevention interventions, education has been proven to be one of the intervention strategies that can help to reduce the number of falls. Education makes it possible for patients and their families to learn about individual risks and become involved in the prevention process. Therefore, the proposed intervention includes the nursing education component and not only environmental or patient identification interventions.

Multifactorial approach is also important when it comes to falls prevention. As proved by Schoberer et al. (2022) after their review of evidence from randomized control trials, multifactorial interventions, education, and counseling have been found to be important tools for falls prevention in hospitals and other healthcare organizations. The results prove the need to use patient education along with the development of individual interventions. Also, according to Mulkey et al. (2023), reduction in the number of falls was achieved through implementation of multifactorial patient-specific fall prevention.

Nurse leadership is especially important for the proposed project. According to Ojo and Thiamwong (2022), the involvement of nurses in fall prevention programs can help to decrease the fall risks among older patients. Nurses are able to assess patients, educate them, assist with mobility, identify changes in patient condition, and communicate about patient risks during the handoff process. AL Ghareeb et al. (2025) identified nursing education, fall prevention strategies, organizational factors, and environment as important elements of acute care fall prevention programs.

There is also the evidence that shows that education and preparedness of the staff members might affect fall prevention practices. According to Negash (2022), there is a relationship between fall prevention education and nursing practice. Therefore, education might be considered necessary in order to implement standardized fall prevention practices. Education of the staff will promote understanding of the purpose of the intervention and expectations associated with assessment, documentation, patient education, and communication.

The described project is aligned with Future of Nursing 2020–2030 report (Wakefield et al., 2021). The main functions of nurses are improvement of the quality of healthcare, change, advancement of health equity, and provision of patient-and family-centered care (Najafpour et al., 2024). A nurse-led fall prevention project reflects all of these principles since it involves implementation of an evidence-based practice to solve an important issue of patient safety.

The described fall prevention project is also supported by health policy and professional standards. The National Performance Goals developed by the Joint Commission stress patient safety and individualized reduction of the risks within healthcare organizations. These goals highlight the need for systematic assessment and individualized interventions in order to reduce the risk of patients' harm. CDC's STEADI provides resources to identify and manage fall risk among older adults. Therefore, the discussed policies and professional recommendations provide the organizational and regulatory background for implementation of the standard fall prevention practices.

The evidence proves that inpatient falls are an important quality and safety issue that should be addressed among the hospitalized patients. Current literature recommends using multifactorial interventions involving assessment, education, individualized prevention interventions, communication, and patient education. The nurse-led bundle described in this paper is feasible in an acute-care setting and can be evaluated within four weeks. Even though it will not allow to draw any conclusions about the sustainability of the intervention due to the limited time, it will provide some evidence about the effectiveness of standardized nursing practices in terms of fall prevention.

References

Agency for Healthcare Research and Quality. (2021). Fall TIPS: A patient-centered fall prevention toolkit. https://www.ahrq.gov/patient-safety/settings/hospital/fall-tips/index.html

AlGhareeb, S. A., AlOtaibi, N. G., Sallam, L. A., & Innab, A. (2025). Nurse-led fall prevention programs in acute care settings: An integrative review. International Journal of Nursing Studies Advances, 9, 100440. https://www.sciencedirect.com/science/article/pii/S2666142X25001456

Centers for Disease Control and Prevention. (2025). Inpatient care: STEADI—Older adult fall prevention. https://www.cdc.gov/steadi/hcp/clinical-resources/inpatient-care.html

Dykes, P. C., Burns, Z., Adelman, J., et al. (2020). Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: A nonrandomized controlled trial. JAMA Network Open, 3(11), e2025889. https://jamanetwork.com/journals/jamanetworkopen/articlepdf/2773051/dykes_2020_oi_200851_1605020862.72395.pdf

Morris, M. E., Webster, K., Jones, C., Hill, A. M., Haines, T., McPhail, S., ... & Cameron, I. (2022). Interventions to reduce falls in hospitals: a systematic review and meta-analysis. Age and ageing, 51(5), afac077. https://academic.oup.com/ageing/article-pdf/51/5/afac077/44060942/afac077.pdf

Mulkey, D. C., Fedo, M. A., & Loresto, F. L., Jr. (2023). Analyzing a multifactorial fall prevention program using ARIMA models. https://journals.lww.com/jncqjournal/fulltext/2023/04000/Analyzing_a_Multifactorial_Fall_Prevention_Program.14.aspx

Wakefield, M. K., Williams, D. R., Le Menestrel, S., & Lalitha, J. (2021). The future of nursing 2020–2030: charting a path to achieve health equity. 2021. National Academy of Sciences, 10, 25982. https://www.researchgate.net/profile/Suzanne-Le-Menestrel/publication/356125792_The_future_of_nursing_2020-2030/links/637799f737878b3e87bfc09d/The-future-of-nursing-2020-2030.pdf

Najafpour, Z., Arab, M., Rashidian, A., Shayanfard, K., Yaseri, M., & Biparva-Haghighi, S. (2024). A stepped-wedge cluster-randomized controlled trial of a multi-interventional approach for fall prevention. Quality Management in Healthcare, 33(2), 77-85. https://journals.lww.com/qmhcjournal/fulltext/2024/04000/a_stepped_wedge_cluster_randomized_controlled.2.aspx

Negash, N. A. (2022). Assessment of self-reported practice of nurses towards fall prevention and its associated factors in an Ethiopian hospital. International Journal of Orthopaedic and Trauma Nursing, 46, 100960. https //www.sciencedirect.com/science/article/pii/S1878124122000405

Ojo, E. O., & Thiamwong, L. (2022). Effects of nurse-led fall prevention programs for older adults: A systematic review. Pacific Rim International Journal of Nursing Research, 26(3), 417–431. https://pmc.ncbi.nlm.nih.gov/articles/PMC9432804/pdf/nihms-1831837.pdf

Schoberer, D., Breimaier, H. E., Zuschnegg, J., et al. (2022). Fall prevention in hospitals and nursing homes: Clinical practice guideline. Worldviews on Evidence-Based Nursing, 19(2), 86–93. https://sigmapubs.onlinelibrary.wiley.com/doi/pdfdirect/10.1111/wvn.12571