NURS FPX 4005 Assessment 4 Stakeholders Presentation

Student Name

Capella University

NURS FPX 4005

Professor Name

Submission Date

Stakeholder Presentation

Slide: 1

I am _________. My presentation is based on a research study to devise an evidence-based strategy to lessen patient fall risks in Green Valley Medical Center’s high-acuity medical-surgical units. There are many reasons why patients in medical-surgical units fall, such as when unit staff members are too busy to respond to a patient’s call for help in a timely manner, or when the staff members responsible for assisting the patient to move about are different from the staff members who receive and document the patient’s mobility order. My presentation will attempt to engage the leadership team to advocate for the development of a collaborative practice framework.

Slide: 2

This presentation provides rationale and an evidence-based plan to reduce patient falls in a high-acuity unit and includes reason(s) to support an interprofessional approach beyond nursing. Multiple professionals touch various aspects of patient falls and therefore, an interprofessional approach is necessary. In the absence of a comprehensive, interprofessional plan to address fall risk, it is expected that silos and communication gaps will exist across professional disciplines. This includes a lack of standardization of screening for patient risk of falls during transfers and/or movement. An interprofessional team will work to screen for patient risk of falls and determine the best approach to ensuring the patient’s safety during the movement. Assistance from management is required to implement the changes described, including allowing unit-based safety officers protection from busy work, and adjusting the EHR to support fall risk management.

Slide: 3

Recurrent Falls in High-Acuity Medical-Surgical Units

Green Valley Medical Center’s medical-surgical unit (MSU) has challenges with patient falls related to lack of assistance during transports, response to call lights, and communication regarding patient mobility. Various units across Green Valley Medical Center, as well as other health care facilities, experience similar issues. The Joint Commission states that more than 700,000 to 1,000,000 patient falls occur in health care facilities in the U.S. each year. The data collected by Green Valley Medical Center for each MSU reflects the fall trends for the U.S. healthcare system, which show either no change or an increase in fall rates. Fall rates can be reduced if the team takes an active role in fall prevention instead of the individual nurse being responsible for fall prevention. Thus, a team approach to preventing falls is imperative.

Slide: 4

Consequences of Not Addressing the Issue

This problem will, ultimately, lead to increased costs and risks. According to Reider and colleagues (2024), in the United States, the annual cost to the health care system for falls by older adults is approximately $22.9 billion. The most medically vulnerable and complicated older adults account for the highest costs. Fractures are the most common serious injuries from falls, and they increase the risk of additional injuries and prolong the recovery and rehabilitation process. One of the most important concerns of the health care staff is to regain the trust of patients and their families by ensuring their safety and well-being and by minimizing the risk of further injuries and falls. Failure to address falls increases the risk of injury, prolongs patient recovery and rehabilitation, and increases the staff’s injury and liability exposure. From a regulatory perspective, failure to limit the number of patient falls increases the burden on the health care facility. This is especially true for Green Valley, where a high number of patient falls increases staff liability exposure and adds to the existing burden on staff.

Slide: 5

Relevance of an Interdisciplinary Team Approach

It should be noted that the prevention of patient falls in high-acuity areas is the responsibility of the entire team and not solely that of the nurses on duty. The results of a recently conducted systematic review and meta-analysis reported that the effectiveness of multiple falls prevention interventions is greater than that of single-intervention falls prevention strategies. The authors noted that the multiple intervention falls prevention strategies were composed of a combination of intervention components, which were informed by the individual patient falls risk factors. It was, therefore, important to have members of the patient’s team (i.e., physician, pharmacist, physical and occupational therapist) who are able to identify and assist in the management of the patient’s mobility and activity level.

Slide: 6

Sources of Evidence Used to Develop the Plan

There is a significant body of evidence to support the various components of this Plan. Pavlova et al. (2022) reported that the best approach to falls prevention is a multidisciplinary approach, which includes members of the patient’s healthcare team. Basic et al. (2021) noted that effective real-time communication among members of a patient care team is key to preventing patient falls. Baumann et al. (2022) supported this view and added that fall prevention is enhanced by effective teamwork and collaboration among members of the healthcare team. Ameri et al. (2025) reported unequal risk among patients in various units, ages, and comorbidities.

Slide: 7

Evidence-Based Interdisciplinary Plan Summary

This interdisciplinary plan summarizes strategies to make the hospital-wide standardized fall prevention program more effective. There will be greater standardization for risk screening, and in real time, communication and accountability will increase. Mobility and risk screening will continue to be the responsibility of the nursing staff. Restrictive conditions, including medication, will be determined by the physician. Mobility goals will be developed by a Physical or Occupational Therapist. Outcome measures will be the responsibility of the Quality Improvement Staff. Decreased communication will continue to be addressed by the interdisciplinary huddles. The mobility status of the patient will be displayed on the Board. The mobility programs and huddles will be introduced first to address barriers for fall prevention. Audits will continue to be performed to evaluate and adjust the new processes. The activities will be performed using the principles of Lewin’s Change Model and transformational leadership.

Slide: 8

Real-World Examples Relevant to the Healthcare Organization

Effective, interdisciplinary, and team-based approaches to fall prevention are evidence-based and have been successfully implemented across numerous settings. Various journal articles describe a number of successful quality improvement projects related to the prevention of patient falls. For example, a number of senior nurses, as fall prevention champions, in conjunction with the Fall Ambassador Safety Team (FAST) program, led an evidence-based fall prevention bundle and progressively reduced patient falls in a progressive care unit in the Providence Health System. In addition, at the University of Sydney, St Vincent’s Hospital, a number of healthcare professionals, including nurses and allied health staff, formed an interdisciplinary team to lead twice-weekly rounds to reduce patient falls. The interdisciplinary team was successful in reducing patient falls in the high-risk, older adult, acute care population. The aforementioned examples clearly demonstrate that the use of an integrated, interdisciplinary team approach to fall prevention is more beneficial than employing a larger number of staff to reduce patient falls.

Slide: 9

Implementation and Resource Management

This component will primarily depend on available resources. The current EHR may be able to be modified to create standardized fields for fall risk screening and alert generation. In the interim, resources would be allocated to other staff members’ fall prevention training as well as the development of champions for fall prevention on each unit. The resources would also be directed to supply less-resourced units with mobility aids. The proposed intervention would be similar to the FAST program, in which the training of a unit-based fall prevention bundle and a fall prevention safety bundle is the main focus of the intervention (Codilla & Arraiza, 2024). The implementation costs for this type of program would be minimal when compared to the costs associated with patient falls. Based on national data, the average cost of a patient fall would be approximately $18,047 (Reider et al., 2024). The proposed intervention would aid in falls prevention and help offset the cost of patient falls. The unit heads and management staff would be charged with oversight of the budget and scheduling for staffing falls prevention activities.

Slide: 10

Evidence-Based Criteria to Evaluate Project Success

Project success will be measured by the following criteria. First, we will look at the monthly unit-level fall rate per 1,000 patient days. Second, we will look at the fall injury rate. Third, we will measure the process by looking at the participation of staff in risk screening and in huddles, as well as using a mobility board. Finally, the choice of the interventions used to reduce the rate of falls will be based on multifactorial, multidisciplinary approaches, as previous research has shown these types of approaches to be more effective. The goal of all of these changes will be to reduce the overall fall and injury rates, while improving the overall communication among all members of the interdisciplinary team.

Slide: 11

Sources of Evidence for Criteria Development

The following measures are directly extracted from the literature used to develop the plan. Reider et al. (2024) state that although it is important to document falls and injuries, it is also critical to assess the injury case severity, as there may be a situation whereby the overall costs of the case will increase due to more severe injuries. Similarly, Pavlova et al. (2022) suggest using process measurements and outcome measurements in combination, as the case may be, that the outcome of a multifaceted approach will be dependent on adherence to the process. From the scoping review conducted by Al-Anati et al. (2024), it is indicated that there are positive effects on patient falls and patient satisfaction when process communication is initiated and effectively implemented. This emphasizes the combination of process and outcome measurements.

Slide: 12

Conclusion

Evidence-based recommendations for the multi-disciplinary strategy to reduce patient falls in the high acuity wards at the Green Valley Medical Center will be developed and implemented with the help of other health facilities. This strategy includes the collaboration of the medical staff, nursing staff, physical therapy staff, and the quality improvement staff. It also includes the use of huddles and electronic health record (EHR) based screenings. It is expected that implementation of this strategy will reduce patient falls, improve communication and teamwork among the health staff, and create a more effective and safer health care service. Other strategies include the appropriate staffing and training of the health personnel. The best way to achieve this is through the approval of the management of the health facility.

References

Al‐Anati, A., Molloy, L., Sim, J., Halcomb, E., & Frost, S. A. (2024). Structured interactions between nurses and patients through intentional rounding: A scoping review. International Nursing Review, 71(3). https://doi.org/10.1111/inr.12984

Ameri, M., Foroozan Faress, Soltani, S., Abbas Aghabiklooei, Leyla Abdolkarimi, & Amirmohammad Babaeigoharrizi. (2025). Risk factors and causes of inpatient falls in a tertiary care hospital in Tehran, Iran: A retrospective study. Archives of Iranian Medicine, 28(7), 412–415. https://doi.org/10.34172/aim.33365

Amina, A., Kassem, A., & Sleem, W. (2022). Applying Lewin’s Change Management theory to improve patients’ discharge plan. Mansoura Nursing Journal (Print), 9(2), 335–348. https://doi.org/10.21608/mnj.2022.295591

Basic, D., Huynh, E. T., Gonzales, R., & Shanley, C. G. (2021). Twice‐weekly structured interdisciplinary bedside rounds and falls among older adult inpatients. Journal of the American Geriatrics Society, 69(3), 779–784. https://doi.org/10.1111/jgs.17007

Baumann, I., Wieber, F., Volken, T., Rüesch, P., & Glässel, A. (2022). Interprofessional collaboration in fall prevention: Insights from a qualitative study. International Journal of Environmental Research and Public Health, 19(17), 10477. https://doi.org/10.3390/ijerph191710477

Codilla, J., & Arraiza, J. (2023). Fall prevention quality initiative: implementation of fall ambassador safety team (FAST). In Providence Digital Commons. https://digitalcommons.providence.org/prov_rn_conf_annual/2024/podiums/6/

Pavlova, A. V., Swinton, P. A., Greig, L., Alexander, L., & Cooper, K. (2022). The effectiveness of multifactorial and multicomponent interventions for the prevention of falls for adults in hospital settings: A systematic review and meta-analysis. https://doi.org/10.1101/2022.05.31.22275666

Randell, R., McVey, L., Wright, J., Zaman, H., Cheong, V.-L., Woodcock, D. M., Healey, F., Dowding, D., Gardner, P., Hardiker, N. R., Lynch, A., Todd, C., Davey, C., & Alvarado, N. (2024). Shared responsibility. In Safer nursing care tool implementation and evaluation in acute hospitals. National Institute for Health and Care Research. https://www.ncbi.nlm.nih.gov/books/NBK602065/

Reider, L., Falvey, J. R., Okoye, S. M., Wolff, J. L., & Levy, J. F. (2024). Cost of United States (U.S.) emergency department and inpatient visits for fall injuries in older adults. Injury, 55(2), 111199. https://doi.org/10.1016/j.injury.2023.111199

Ystaas, L. M. K., Nikitara, M., Ghobrial, S., Latzourakis, E., Polychronis, G., & Constantinou, C. S. (2023). The impact of transformational leadership in the nursing work environment and patients’ outcomes: A systematic review. Nursing Reports, 13(3), 1271–1290. https://doi.org/10.3390/nursrep13030108