Date of Award

Winter 12-22-2016

Degree Type

Final Project

Degree Name

DNP Doctor of Nursing Practice




MaryEllen Roberts, D.N.P.

Committee Member

Eileen Toughill, Ph.D.

Committee Member

David Rivera


Patient falls in the United States (US) range from 700,000 to one million annually and one third of those falls can be prevented (Du Pree, Fritz-Campiz & Musbeno, 2014). Twenty to 30% of falls are moderate to severe (Schimke & Schimke, 2014). As of 2009, The Joint Commission’s (TJC) (2015) Sentinel Event databank held 465 reports of hospital falls with injury; deaths that resulted in those injuries were reported as 63 percent. Common denominators resulting in patient falls with injury are poor assessment, lack of communication, failure to follow protocols, insufficient training and supervision, staffing levels, unsafe environments and lack of leadership (TJC, 2015). The average cost per fall in hospitals is $17,293.00 (Trepanier & Hillsenbeck 2014). CMS categorizes patient falls as a healthcare acquired condition (Du Pree et al., 2014). The cost of injuries from falls occurring in acute care facilities is not reimbursed by the Centers for Medicare & Medicaid Services (CMS) (Du Pree et al., 2014). Preventing patient falls is multifaceted and necessitates commitment from all staff within acute care facilities.

Care improvement is noted in the literature through use of a Safety Culture, thus this DNP project was designed to improve care by developing a falls prevention education program within a Safety Culture. The DNP project of discussion was piloted in a 475-bed acute care facility. The neurological-medical unit suffered higher fall rates than other units in the facility; therefore, it was an ideal candidate for a falls prevention education program within a Safety Culture framework. Three ancillary departments were chosen to participate in the pilot because they have continuous contact with patients and families.

Before implementation, educational methods were discussed with the stakeholders, as well as the importance of leadership’s role in a Safety Culture. Once these were approved, dates for the educational sessions were arranged. The goal of the project was to educate ancillary staff on the importance of patient safety within a Safety Culture framework.