Document Type



Doctor of Nursing Practice



Date of Defense


Graduate Advisor

Anne Thatcher


Susan Dean-Baar


Sara Jackson



Problem: Inpatient falls are a major patient safety issue. Behavioral health units experience higher rates of falls among elderly patients with between 13.1 to 25 falls per 1,000 occupied bed days (OBD). The risk of falls for the aged population is increased on a psychiatric unit due to a myriad of issues including psychotropic medications, over-activity on the unit, and confusion (Wong & Pang, 2019).

Methods: This QI project is an observational descriptive pilot intervention evaluation of a redesigned fall prevention program with the aim to reduce falls on a midsized suburban Midwestern inpatient geriatric behavior health unit by 10%. A retrospective and prospective case record review of falls was evaluated three months pre and post implementation.

Results: During the pre-pilot period, 15.65 falls occurred per 1,000 OBD and post-pilot, 4.37 falls occurred per 1,000 PBD. An unpaired t-test, resulted in a p- value of 0.1180, showing no statistically significant reduction of falls after implementation. This data may be skewed as one patient experienced seven falls during their admission in the pre-implementation period, with suspected behavioral intent.

Conclusion: The findings of this study highlight the need for continued practice improvement to reduce the likelihood of falls. Reinforcing current policy for implementation and required documentation would assist in the determination of overall improvement. Barriers to adequate implementation and documentation needed to be addressed by the administration of the older adult behavioral health unit to determine if workforce needs or lack adequate fall prevention equipment were factors in the omission of required implementation strategies and documentation.