Date of Conferral



Doctor of Nursing Practice (DNP)


Health Services


Carolyn Sipes


A Magnet-recognized academic hospital system experienced an increase in patient falls and patient falls with injury after transitioning to a new electronic health record. The purpose of the project was to evaluate the effectiveness of a system-wide quality improvement practice change. The practice-focused question addressed a Magnet model implementation of a standardized, system-wide, evidence-based Hester Davis Scale (HDS) fall risk assessment and intervention tool and the impact on the nursing-sensitive indicators of patient fall rates and fall rates with injury. Successful implementation and sustained, correct use of the HDS fall risk assessment and targeted fall-prevention-intervention tools added to the evidence of multifactorial fall-intervention-prevention strategies designed to reduce patient falls and patient injury associated with falls. Two models were used to inform the project: the American Nurses Credentialing Center next-generation Magnet model and the Institute for Healthcare Improvement framework for spread. The primary source of evidence was the National Database of Nursing Quality Indicators. A run chart approach to process improvement was determined to be the best method to assess the effectiveness of the HDS Falls Prevention Program for 28 months post implementation. The run chart for patient fall rates and fall with injury rates demonstrated a reduction in falls and sustained improvement over 28 months. The decreases in falls and fall with injury rates of this project have implications for positive social change. Magnet recognition supports the implementation of the evidence-based HDS Fall Reduction Program, thereby improving the quality of life for patients and families and reducing the burden and cost of health care associated with falls.

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Nursing Commons