ABSTRACT

Patient falls represent a critical safety issue, ranking as the third most common sentinel event in 2022 and contributing to increased morbidity, mortality, and healthcare costs. Despite the widespread use of fall prevention programs, their effectiveness is often hindered by gaps in nurse education and patient engagement. To address these challenges, a hospital in Arizona experiencing a rise in fall rates implemented the Fall TIPS (Tailoring Interventions for Patient Safety) Toolkit, a nurse-led, three-step fall prevention program. The toolkit provides individualized interventions based on patients’ fall risk, engages patients each shift in developing personalized prevention plans, and uses a bedside visual poster to communicate these plans to the care team.

This quality improvement project aimed to improve registered nurses’ fall prevention knowledge and perceived workflow efficiency. A pre- and post-test design was used to assess changes using digital surveys distributed via QR codes. Eligible participants included English-speaking Registered Nurses, aged 18 and older, working on the hospital’s medical-surgical unit. Participation was voluntary and anonymous, and the project received exempt status from the Institutional Review Board.

Findings demonstrated a significant improvement in nurses’ fall prevention knowledge and perceived efficiency following the implementation of the Fall TIPS Toolkit. Additionally, a reduction in patient fall and fall injury rates was observed on the unit during the five-month implementation period, despite increasing fall and fall injury rates across the hospital overall. These results support the effectiveness of the toolkit in enhancing staff preparedness, patient education, and improving patient safety outcomes.