Date of Conferral
5-2-2025
Date of Award
May 2025
Degree
Doctor of Nursing Practice (DNP)
School
Nursing
Advisor
Maria Revell
Abstract
Following a 16% increase in patient falls from 2023 to 2024 in an inpatient psychiatric detoxification unit, a quality improvement education project was implemented to assess the impact of an evidence-based fall prevention bundle on fall rates and nursing compliance. Nurses received education through a PowerPoint presentation to enhance understanding and implementation of the bundle, which included Edmonson reassessments after high-risk medication administration, ISHAPED bedside shift handoffs, care plan updates, and SWIFT daily safety huddles. Posttests identified that the objective score of 80% knowledge for nurses was met. During the 10-week implementation, the goal was 100% compliance with all bundle elements and a 4% fall reduction. Nurses achieved 91% compliance with Edmonson assessments and ISHAPED handoffs, 68% with SWIFT huddles, and 66% with care plan updates. Although full compliance was not met, the intervention resulted in a 100% reduction in falls, exceeding the 4% target and demonstrating the effectiveness of structured fall prevention strategies in psychiatric detoxification settings. The project emphasized the need for ongoing staff education and monitoring to sustain adherence to safety protocols, particularly improving SWIFT huddle participation and care plan documentation. Beyond enhancing patient safety, this staff education project fostered collaboration through structured handoffs and team huddles while ensuring equitable care by standardizing fall prevention for all patients, addressing health disparities and promoting patient-centered safety measures.
Recommended Citation
Jalloh, Ramatu Dougrey, "Executive Summary: Development of an Evidence-Based Prevention Bundle to Reduce Falls on an Inpatient Psychiatric Detoxification Unit" (2025). Walden Dissertations and Doctoral Studies. 17697.
https://scholarworks.waldenu.edu/dissertations/17697
