NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Name

Capella university

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Prof. Name

Date

Improvement Plan Tool Kit

This toolkit is developed to support nurses and healthcare providers in the execution and maintenance of effective, evidence-based patient safety programs, particularly targeting the reduction of falls in hospital environments. It includes curated clinical and scholarly resources that offer practical strategies, risk assessment tools, patient education approaches, and technological aids to strengthen fall prevention initiatives. Each tool is presented with clear descriptions, guidelines for application in real-world settings, and implementation instructions. The use of this toolkit empowers nurses to elevate safety outcomes and care quality across healthcare settings.

The selection of resources for this toolkit was based on specific keyword searches including “fall prevention,” “patient safety,” “risk assessment,” “root cause analysis,” and “evidence-based nursing practice.” These terms helped identify the most relevant literature and tools supporting practical interventions in clinical settings. Each element in the toolkit is structured to align with clinical workflows and encourages the integration of safety strategies into everyday patient care processes. Nurses are positioned to bridge the gap between research and practice by leveraging these tools during safety assessments and care planning.

Environmental Risk Reduction and Safety Assessments

Environmental hazards play a critical role in increasing the risk of falls, especially among elderly patients in both hospital and home settings. Campani et al. (2021) provide a thorough assessment strategy designed to evaluate and modify home environments. Interventions such as removing trip hazards, improving lighting, and installing support devices have shown effectiveness in reducing fall incidents. These interventions are ideal for both community health nurses and hospital staff managing post-discharge safety planning.

A tabular representation of fall risk factors and corresponding environmental interventions is outlined below:

Locklear et al. (2024) emphasize the scale of the problem, estimating that 700,000 to 1 million in-patients fall each year in U.S. hospitals. Cognitive impairment contributes significantly to fall risk, underscoring the importance of accurate risk identification. They advocate for assessment tools like the Morse Fall Scale and emphasize hourly rounding and staff training as effective countermeasures. Their findings support integrating structured fall prevention protocols into care planning to improve patient safety and reduce financial burdens related to fall injuries.

Furthermore, Stathopoulos, Hansson, and Stigmar (2021) investigate how hospital design and systemic factors such as overcrowding influence fall rates. Their findings point out that 89% of inpatient falls occur in patient rooms and are most prevalent in neurology and orthopedic departments. Overcrowded wards—impacted in 75% of the studied clinics—were found to severely hinder fall prevention efforts. Hospital administrators and nursing leadership can use these findings to advocate for operational changes, such as increased staffing or facility redesigns, to mitigate such risks.

Staff Education and Patient-Centered Care Strategies

Improving fall prevention also requires a shift toward education and patient-focused care strategies. Albertini et al. (2022) describe a Brazilian initiative that implemented person-centered care strategies to reduce falls in hospital settings. This approach blends individualized care plans with environmental modifications based on each patient’s unique risks. Staff training in these customized strategies resulted in a dramatic increase in compliance—from 62% to 92%—with fall prevention protocols.

Another key aspect of effective fall prevention is structured communication. Mulfiyanti and Satriana (2022) explored the role of the SBAR (Situation, Background, Assessment, Recommendation) communication framework in nursing handovers. Their study shows that SBAR significantly enhances the clarity and accuracy of information transmission during nurse shift changes. This reduces the likelihood of falls by ensuring all staff are aware of a patient’s current status and risk factors. This communication model is especially valuable during interprofessional collaboration and urgent care transitions, promoting both safety and teamwork in high-pressure environments.

Additionally, Garcia et al. (2021) examined nurses’ perspectives on recommended fall prevention methods. Their study shows that multi-factorial strategies—especially those that incorporate patient education with environmental changes—are viewed as most effective. However, they also identified key barriers to implementation, such as time constraints and lack of organizational support. These findings suggest a need for leadership to provide staff with adequate time, resources, and training to implement evidence-based interventions successfully.

Finally, Linnerud et al. (2023) detailed a collaborative, stakeholder-driven model for designing fall prevention strategies in Norwegian home-care settings. Their co-creation model emphasizes regional adaptability and community engagement. This strategy empowers frontline nurses and caregivers to tailor fall prevention measures based on patient demographics and localized needs. The approach also supports the long-term sustainability of safety programs through stakeholder involvement from inception.

References

Albertini, A. C. da S., Fernandes, R. P., Püschel, V. A. de A., & Maia, F. de O. M. (2022). Person-centered care approach to prevention and management of falls among adults and aged in a Brazilian hospital: A best practice implementation project. JBI Evidence Implementation, 21(1), 14–24. https://doi.org/10.1097/xeb.0000000000000356

Campani, D., Caristia, S., Amariglio, A., Piscone, S., Ferrara, L. I., Barisone, M., Bortoluzzi, S., Faggiano, F., Dal Molin, A., Silvia Zanetti, E., Caldara, C., Bellora, A., Grantini, L., Lombardi, A., Carimali, C., Miotto, M., Pregnolato, A., & Obbia, P. (2021). Home and environmental hazards modification for fall prevention among the elderly. Public Health Nursing, 38(3), 493–501. https://doi.org/10.1111/phn.12852

Garcia, A., Bjarnadottir, R. (Raga) I., Keenan, G. M., & Macieira, T. G. R. (2021). Nurses’ perceptions of recommended fall prevention strategies. Journal of Nursing Care Quality. https://doi.org/10.1097/ncq.0000000000000605

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Linnerud, S., Aimée, L., Graverholt, B., Idland, G., Taraldsen, K., & Brovold, T. (2023). Stakeholder development of an implementation strategy for fall prevention in Norwegian home care – a qualitative co-creation approach. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-10394-x

Locklear, T., Kontos, J., Brock, C. A., Holland, A. B., Hemsath, R., Deal, A., Leonard, S., Steinmetz, C., & Biswas, S. (2024). In-patient falls: Epidemiology, risk assessment, and prevention measures. A narrative review. HCA Healthcare Journal of Medicine, 5(5). https://doi.org/10.36518/2689-0216.1982

Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275

Stathopoulos, D., Hansson, E. E., & Stigmar, K. (2021). Exploring the environment behind in-patient falls and their relation to hospital overcrowdedness—a register-based observational study. International Journal of Environmental Research and Public Health, 18(20), 10742. https://doi.org/10.3390/ijerph182010742