Capella FPX 4035 Assessment 3
Student Name
Capella University
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Improvement Plan In-Service Presentation
Part 1: Agenda and Learning Outcomes
Welcome, everyone. I’m [Insert Name], and today we’ll be focusing on fall prevention, a vital concern for patient safety in healthcare. This session will equip you with practical tools to minimize fall incidents and strengthen our interdisciplinary collaboration.
The objective of today’s training is to enhance staff competency in preventing patient falls, which continue to be a pressing concern due to their potential to cause long-term injuries, increase hospital stays, and raise treatment costs (Khawaja et al., 2023). We aim to address this issue through three structured goals:
Goal 1: Analyze the Core Causes of Patient Falls
This section will review common contributors to patient falls within our healthcare setting. These include inconsistent use of risk assessments, environmental hazards, and communication breakdowns during shift changes (Takase, 2022).
Goal 2: Assess Evidence-Based Fall Prevention Strategies
We will review fall mitigation techniques, such as the Morse Fall Scale and environmental adjustments that have been validated through recent research (Miura & Kanoya, 2025).
Goal 3: Apply Practical Interventions to the Safety Plan
We will conclude with hands-on practice to help you integrate fall prevention measures in your daily routine, improving your ability to identify risks and apply preventive strategies.
Expected Learning Outcomes:
- Identify primary causes of patient falls and areas for procedural improvement.
- Understand and apply evidence-based practices to reduce fall rates.
- Build confidence and proficiency in risk assessment and safety protocols.
Part 2: Safety Improvement Plan
Current Fall Risks in the Organization
Patient falls remain a persistent challenge in healthcare environments. Studies show that approximately 30–35% of falls result in serious injury, including fractures and head trauma (Garcia et al., 2021). These incidents often stem from preventable factors such as poor lighting, clutter, and miscommunication during handoffs.
Table 1: Environmental Factors Contributing to Falls
| # | Environmental Factor |
|---|---|
| 1 | Inadequate lighting |
| 2 | Obstructed walkways |
| 3 | Slippery or wet surfaces |
| 4 | Uneven flooring |
| 5 | Absence of grab bars or handrails |
| 6 | Incorrect bed or chair height |
| 7 | Malfunctioning equipment |
| 8 | Unsuitable footwear |
| 9 | Overcrowded environments |
| 10 | Inconvenient placement of call buttons |
According to Takase (2022), 79% of patient falls were unwitnessed, while 8.7% occurred during active nursing care. The need for consistent assessment and communication strategies is evident to reduce these events.
Proposed Fall Prevention Strategy
Our safety strategy includes three major steps:
- Risk Assessment via the Morse Fall Scale – A validated tool for consistent fall risk screening.
- Environmental Modifications – Installing alarms, improving lighting, and ensuring clear walkways (Lakbala et al., 2024).
- Staff Training and SBAR Communication – Training sessions to promote accurate information transfer using SBAR (Mulfiyanti & Satriana, 2022).
SBAR Example:
- Situation: “Patient is at high risk due to recent dizziness.”
- Background: “History of falls and current use of sedatives.”
- Assessment: “Unstable gait; needs supervision.”
- Recommendation: “Use bed alarms, non-slip socks, hourly rounding.”
Part 3: Staff Involvement and Benefits
Roles and Responsibilities in Implementation
As frontline caregivers, nursing staff are essential to executing this plan. Responsibilities include:
- Conducting daily Morse Fall Scale assessments.
- Reporting and correcting environmental hazards.
- Using SBAR for accurate shift-to-shift handoffs.
These actions are practical and designed to become a routine part of patient care (Lakbala et al., 2024).
Why Your Role is Pivotal
Nursing staff serve as the first defense against patient falls. Your constant presence allows you to observe and intervene in real-time. Your cooperation in communication and immediate response fosters a proactive safety culture (Mulfiyanti & Satriana, 2022).
Benefits of Active Engagement
Embracing this role leads to:
- Reduced patient injuries and better outcomes.
- Less stress from managing fall aftermath.
- Greater job satisfaction from contributing to safer care (Ojo & Thiamwong, 2022).
Part 4: Skills and Process Application
New Skills for Effective Practice
Participants will develop the following skills:
- Conducting Morse Fall Scale evaluations.
- Identifying and mitigating environmental hazards.
- Implementing SBAR for seamless information transitions (Lakbala et al., 2024).
These tools enhance interprofessional consistency and reduce patient harm.
SBAR Role-Play Exercise
Each participant will engage in a one-minute SBAR handoff scenario involving a 72-year-old patient who fell the previous day due to medication-induced dizziness. Teams will practice delivering and receiving concise, structured reports. Feedback will be provided in real-time to refine your communication approach.
Conclusion
This in-service session provided a comprehensive strategy for fall prevention. We reviewed causes and consequences, introduced a structured plan with standardized tools, and practiced essential skills like the Morse Fall Scale and SBAR communication. By participating, you play a vital role in transforming our facility into a safer environment for everyone.
References
Dykes, P. C., Bowen, M. C., Lipsitz, S., Franz, C., Adelman, J., Adkison, L., Bogaisky, M., Carroll, D., Carter, E., Herlihy, L., Lindros, M. E., Ryan, V., Scanlan, M., Walsh, M.-A., Wien, M., & Bates, D. W. (2023). Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. JAMA Health Forum, 4(1), e225125. https://doi.org/10.1001/jamahealthforum.2022.5125
Ernstmeyer, K., & Christman, E. (2021). Chapter 5 Safety Introduction. Www.ncbi.nlm.nih.gov; Chippewa Valley Technical College. https://www.ncbi.nlm.nih.gov/books/NBK591826/
Garcia, A., Bjarnadottir, R. (Raga) I., Keenan, G. M., & Macieira, T. G. R. (2021). Nurses’ perceptions of recommended fall prevention strategies. Journal of Nursing Care Quality, Publish Ahead of Print(3). https://doi.org/10.1097/ncq.0000000000000605
Capella FPX 4035 Assessment 3
Khawaja, I., Awan, S. A., azam, D. masroor, Babar, M., Khan, Dr. T., & Khalil, M. owais. (2023). Fall prevalence and associated risk factors in the hospitalised adult population: A crucial step towards improved hospital care. Cureus, 15(8), e44146. https://doi.org/10.7759/cureus.44146
Lakbala, P., Bordbar, N., & Fakhri, Y. (2024). Root cause analysis and strategies for reducing falls among inpatients 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
Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275
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. https://pmc.ncbi.nlm.nih.gov/articles/PMC9432804/
Takase, M. (2022). Falls as the result of interplay between nurses, patient and the environment: Using text-mining to uncover how and why falls happen. International Journal of Nursing Sciences, 10(1), 30–37. https://doi.org/10.1016/j.ijnss.2022.12.003