Preferred Name

Deidra Pennington

Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Date of Graduation


Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing


Jeannie Garber

Stephen Lovern


Patient falls remain a significant concern for hospitals despite years of focus and research on the topic. Most hospitals have robust fall prevention policies in place containing numerous interventions, yet few demonstrate evidence of long-term sustainability in fall reduction. Patient falls impact overall health outcomes and result in higher costs for the patient and facility due to increased lengths of stay and more medical tests. The location for this study was the cardiovascular progressive care unit (CVPCU) at a Level 1 Trauma Center and academic hospital. This unit underwent a relocation and merger of two nursing units in the fall of 2018. Literature supports that patient quality suffers during unit restructuring and reorganization. A quality improvement project incorporating a Plan-Do-Study-Act (PDSA) format was implemented to provide ongoing analysis. Interprofessional intentional rounds were implemented following staff education and placement of a 5 P’s reminder sign over each patient bed. A short qualitative survey was distributed to nursing staff at the end of each PDSA cycle to determine barriers and facilitators of the process. Measurements to gauge fall reduction efforts were the number of monthly falls and falls per 1000 patient. The number of monthly falls decreased to 0 during the third and fourth PDSA cycle. Falls per 1000 patients days decreased from 2.72 to 1.46. Thematic analysis of staff surveys revealed benefit of reminder signs, staffing ratios, teamwork, and personal accountability. Recommendations include developing formal interprofessional rounding processes on high-risk fall patients and utilizing reminders to improve effectiveness of rounds.

Included in

Nursing Commons



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