Student Name
Capella University
NURS-FPX4035 Enhancing Patient Safety and Quality of Care
Prof. Name
Date
Improvement Plan Tool Kit
Medical care providers and nurses can leverage this toolkit to design, implement, and sustain evidence-based patient safety initiatives aimed at reducing in-hospital falls. It compiles rigorously selected scholarly and clinical resources that outline key methodologies, risk assessment instruments, patient education approaches, and technological interventions. Each entry includes a concise overview, guidance on integrating the practice into clinical workflows, and practical tips for real-world application. By adopting these tools, nursing teams can enhance quality and safety outcomes across diverse care settings. The toolkit’s development was guided by targeted terms such as “fall prevention,” “patient safety,” “risk assessment,” “root cause analysis,” and “evidence-based nursing practice.”
Annotated Bibliography
This collection of nine studies spans organizational best practices, environmental modifications, communication strategies, educational programs, and quality improvement processes. It highlights multidisciplinary approaches—from stakeholder engagement in home care to technology-driven night-time monitoring—demonstrating how tailored interventions can effectively lower fall rates. The following table synthesizes each resource’s purpose, principal findings, and implementation recommendations.
| Authors (Year) | Focus | Key Findings | Recommended Use |
|---|---|---|---|
| Garcia et al. (2021) | Multifactorial hospital prevention strategies | Nurses favor combining patient education with environmental adjustments for optimal fall reduction. | Guide training modules during fall-prevention program rollouts. |
| Linnerud et al. (2023) | Co-creation of fall prevention in home care | Stakeholder-driven plans tailored to community needs ensure sustainable adoption by home-care nurses and clients. | Host early-stage workshops with frontline staff and caregivers. |
| Mulfiyanti & Satriana (2022) | SBAR communication impact on handovers | Structured SBAR exchanges significantly improve information accuracy, reducing safety incidents such as falls. | Implement during shift changes, interdisciplinary huddles, and crises. |
| Campani et al. (2021) | Home hazard assessments for elderly | Home modifications (e.g., grab bars, improved lighting) markedly decrease community-dwelling seniors’ fall risks. | Integrate into discharge planning and community nursing visits. |
| Locklear et al. (2024) | In-patient fall epidemiology and prevention | Use of risk scales (e.g., Morse Fall Scale), hourly rounding, and assistive devices lowers fall incidence and costs. | Apply during admission assessments and in ongoing staff training. |
| Stathopoulos et al. (2021) | Environmental factors and hospital overcrowding | Overcrowded units with high noise and limited space see increased falls; most occur in patient rooms in neurology/ortho. | Inform policy on staffing ratios and facility space planning. |
| Albertini et al. (2022) | Person-centered care in hospital fall prevention | Individualized care plans raised staff protocol adherence from 62% to 92% and cut fall rates by 30%. | Use in staff orientation and personalized care planning sessions. |
| Heng et al. (2020, 2022) | Patient education for fall prevention | Multimedia and printed education, combined with nurse support, boost patient awareness and reduce falls by 15–25%. | Deliver at admission, discharge, and high-risk assessments. |
| Lakbala et al. (2024); Miura & Kanoya (2025); Ruiz et al. (2022) | RCA, nursing home risk assessment, and sensor-based monitoring | RCA uncovers systemic risk factors; TUG test predicts falls with 85% accuracy; sensor systems cut nighttime falls by 28%. | Employ in post-fall reviews, long-term care assessments, and tech pilots. |
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
Campani, D., Caristia, S., Amariglio, A., Piscone, S., Ferrara, L. I., Barisone, M., … Obbia, P. (2021). Home and environmental hazards modification for fall prevention among the elderly. Public Health Nursing, 38(3), 493–501. https://doi.org/10.1111/phn.12852
Garcia, A., Bjarnadottir, R. I., Keenan, G. M., & Macieira, T. G. R. (2021). Nurses’ perceptions of recommended fall prevention strategies. Journal of Nursing Care Quality. https://doi.org/10.1097/ncq.0000000000000605
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
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
Linnerud, S., Aimée, L., Graverholt, B., Idland, G., Taraldsen, K., & Brovold, T. (2023). Stakeholder development of an implementation strategy for fall prevention in Norwegian home care – a qualitative co-creation approach. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-10394-x
NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit
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
Ruiz, J. F.-B., Chaparro, J. D., Romero, M. J. S., Molina, F. J. V., García, X. del T., Peño, C. B., … 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
Stathopoulos, D., Hansson, E. E., & Stigmar, K. (2021). Exploring the environment behind in-patient falls and their relation to hospital overcrowdedness—a register-based observational study. International Journal of Environmental Research and Public Health, 18(20), 10742. https://doi.org/10.3390/ijerph182010742
NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit
Locklear, T., Kontos, J., Brock, C. A., Holland, A. B., Hemsath, R., Deal, A., … Biswas, S. (2024). In-patient falls: Epidemiology, risk assessment, and prevention measures. A narrative review. HCA Healthcare Journal of Medicine, 5(5). https://doi.org/10.36518/2689-0216.1982