Capella FPX 4035 Assessment 4

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan Tool Kit

Overview of the Toolkit

Healthcare professionals, particularly nurses, can use this improvement toolkit to implement and sustain evidence-based strategies aimed at reducing patient falls in clinical settings. The toolkit comprises curated scholarly and practice-oriented materials that emphasize risk identification, patient and staff education, safety technology integration, and implementation guidelines. Each tool offers detailed descriptions, practical applications, and step-by-step directions for integration into care processes. Nurses leveraging these resources can drive enhancements in both patient safety and care quality across various settings. The toolkit’s foundation stems from search terms like “fall prevention,” “patient safety,” “risk assessment,” “root cause analysis,” and “evidence-based nursing.”

Annotated Bibliography

Organizational Safety and Fall Prevention Best Practices

Garcia et al. (2021) explored nurses’ views on effective fall prevention interventions and discovered that combining patient education with environmental modifications was most effective. These multi-faceted strategies aligned with both patient-specific risks and situational variables. However, nurses reported barriers such as limited time, patient engagement difficulties, and insufficient organizational support. The study underscores the importance of aligning fall prevention practices with clinical realities and calls for targeted training led by nurse leaders to address these practical challenges.

In a qualitative study, Linnerud et al. (2023) discussed how Norwegian stakeholders co-developed an implementation strategy tailored to local home-care conditions. Emphasizing a participatory approach, the research highlights the value of including front-line nursing staff in creating sustainable fall prevention programs. The resource is particularly beneficial for nurses working in home-care settings who wish to customize interventions for older adults living independently. Nurse managers can also apply this resource to facilitate collaborative workshops when designing new safety initiatives.

Mulfiyanti and Satriana (2022) assessed the impact of SBAR (Situation, Background, Assessment, Recommendation) on nursing handovers and its implications for patient safety. The study found SBAR significantly improved communication accuracy, particularly during shift changes and emergency reporting, thereby lowering the risk of falls. The structured approach increased confidence and teamwork among nurses. This tool is valuable in high-acuity units where timely and accurate information exchange is critical to patient safety.

Environmental Risk Reduction and Safety Assessments

Campani et al. (2021) provided insights into how modifying environmental risk factors can prevent falls among elderly patients. Interventions such as removing tripping hazards and installing grab bars were found to reduce risk. Nurses can conduct home safety assessments and recommend targeted changes, making this resource ideal for community health nurses and discharge planners.

Locklear et al. (2024) conducted a comprehensive review detailing the causes, risk factors, and prevention measures related to in-patient falls. With an estimated 700,000 to 1 million in-patient falls annually, the report supports using tools like the Morse Fall Scale and interdisciplinary strategies such as hourly rounding. The review also addresses the financial burden of falls and emphasizes the economic benefits of structured prevention efforts. Nurse leaders can utilize this resource for staff training and for evaluating prevention programs.

Stathopoulos et al. (2021) investigated how hospital overcrowding contributes to in-patient falls. The study linked high fall rates to environmental stressors like noise, limited space, and inadequate staffing. With patient rooms being the most frequent fall locations, the resource helps administrators and QI teams advocate for policy changes that increase staffing levels or expand hospital space.

Improvement Plan Tool Kit: Annotated Bibliography

Staff Education and Patient-Centered Care Strategies

Albertini et al. (2022) introduced a person-centered care strategy for preventing falls within a Brazilian hospital. Their initiative focused on tailoring care plans to individual patient needs, integrating educational interventions for staff, and customizing environmental settings accordingly. This approach significantly improved staff adherence to fall prevention practices, with compliance rising from 62% to 92%. A notable benefit was a 30% reduction in patient falls by targeting individual risk factors like mobility and medication use. The resource is especially relevant for clinical educators and nurse leaders when developing targeted training and quality improvement (QI) programs.

In a scoping review, Heng et al. (2020) examined educational strategies used in hospitals to reduce patient falls. They found that multimedia education methods, including videos and handouts, along with personal discussions, empowered patients with fall prevention strategies. These interventions were particularly effective when delivered at crucial times such as admission and discharge. The study emphasized the need for proactive patient engagement to reduce unattended fall events, which often result in injuries such as fractures and psychological trauma.

Heng et al. (2022) later conducted a mixed-methods trial that assessed the impact of structured patient education. They discovered that using visual aids and active staff participation increased patient awareness of fall risks by 25% and contributed to a 15% fall rate reduction over six months. This evidence supports the integration of patient education programs into nurse-led initiatives, especially during hospital orientation and physical therapy sessions, to optimize safety outcomes.

Fall Event Reporting, Monitoring, and Quality Improvement

Lakbala et al. (2024) emphasize the importance of Root Cause Analysis (RCA) in understanding and addressing the systemic factors behind inpatient falls. The authors explain how RCA assists in identifying risks such as sedative use, which accounts for nearly 40% of falls. The study supports using tools like environmental adjustments and bed alarms to reduce falls by up to 20% in high-risk areas. It is ideal for post-fall analysis, staff training, and enhancing organizational safety protocols.

Miura and Kanoya (2025) focus on fall risk assessments in nursing homes, advocating for validated tools like the Timed Up and Go (TUG) test. Their review shows that TUG accurately predicts fall risk 85% of the time. When paired with team-led exercise sessions, this tool resulted in a 35% fall reduction over a year. These findings highlight the necessity of regular evaluations and interprofessional collaboration in long-term care.

Ruiz et al. (2022) examine the use of sensory technology for fall detection in elderly patients. Their system, designed for nighttime use, detects bed exits with 92% accuracy and helped reduce nighttime falls by 28% in six months. This study supports integrating technological systems into geriatric care for early intervention and efficient monitoring.

Value of Resources

The referenced resources collectively offer high-value strategies for reducing inpatient falls through diverse yet complementary methods. Albertini et al. (2022) prioritize person-centered interventions, while Heng et al. (2020, 2022) demonstrate the power of structured patient education. Lakbala et al. (2024) offer insights into RCA techniques to uncover fall-related systemic flaws. Similarly, Miura and Kanoya (2025) support the use of reliable assessment tools in long-term settings. Ruiz et al. (2022) contribute technological solutions, demonstrating the effectiveness of sensor-based detection systems. These findings are highly applicable for nurses and healthcare administrators aiming to implement evidence-based, patient-specific interventions.

References

Albertini, A. C. da S., Fernandes, R. P., Püschel, V. A. de A., & Maia, F. de O. M. (2022). Person-centered care approach to prevention and management of falls among adults and aged in a Brazilian hospital: A best practice implementation project. JBI Evidence Implementation, 21(1), 14–24. https://doi.org/10.1097/xeb.0000000000000356

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A.-M., & Morris, M. E. (2020). Hospital falls prevention with patient education: A scoping review. BMC Geriatrics, 20(1), 1–12. https://doi.org/10.1186/s12877-020-01515-w

Heng, H., Kiegaldie, D., Shaw, L., Jazayeri, D., Hill, A.-M., & Morris, M. E. (2022). Implementing patient falls education in hospitals: A mixed-methods trial. Healthcare, 10(7), 1298. https://doi.org/10.3390/healthcare10071298

Capella FPX 4035 Assessment 4

Lakbala, P., Bordbar, N., & Fakhri, Y. (2024). Root cause analysis and strategies for reducing falls among in-patients in healthcare facilities: A narrative review. Health Science Reports, 7(7). https://doi.org/10.1002/hsr2.2216

Miura, T., & Kanoya, Y. (2025). Fall risk assessment and prevention strategies in nursing homes: A narrative review. Healthcare, 13(4), 357–357. https://doi.org/10.3390/healthcare13040357

Ruiz, J. F.-B., Chaparro, J. D., Romero, M. J. S., Molina, F. J. V., García, X. del T., Peño, C. B., Solano, H. L., Colantonio, S., Revuelta, F. F., & López, J. C. (2022). Bedtime monitoring for fall detection and prevention in older adults. International Journal of Environmental Research and Public Health, 19(12), 7139. https://doi.org/10.3390/ijerph19127139