Date of Conferral

2015

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Marilyn Murphy

Abstract

The literature supports that a Unit Safety Champion (USC) may reduce falls among hospitalized patients. The purpose of this project was to determine if the implementation of a USC would assist in reducing falls on an acute unit in an urban hospital environment. The frequency of patient falls on the unit was collected from the hospital's quality department 3 months before and 3 months after the implementation of the USC. The average number of falls for 3 months before implementation was 5.0 per month (SD = 2.65) and involved a total of 15 individual patients. The average number of falls for 3 months after implementation was 5.33 (SD = 1.53) and involved a total of 16 individual patients. Although the average number of falls increased, there was no statistically significant difference in the average number of falls between these time periods. Upon further investigation, it was discovered that the unit experienced an increase in nursing turnover while implementing the USC. Although this confounding variable was not examined as part of this project, the results demonstrate the importance of nursing turnover on adverse patient events. The literature suggests that front-line workers may contribute to a quality change in the acute environment. Using Lewin's change model as a foundation, an action plan was submitted to the fall committee emphasizing the relational importance of nurse staffing management and adverse events. It is recommended that a longitudinal project be conducted to fully understand the contribution of the USC to the unit.

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