NURS FPX 4035 Assessment 4

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

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Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

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Improvement Plan Tool Kit

The Improvement Plan Tool Kit is a strategic resource developed for healthcare professionals, particularly nurses, to facilitate the implementation of evidence-based safety initiatives centered around fall prevention in hospitals. This toolkit includes a variety of clinically validated and academically supported tools that emphasize best practices in fall prevention. The contents cover patient education, environmental risk assessments, safety protocols, and integration of technology. Each tool is supplemented with a description, implementation guidance, and information on clinical relevance to ensure a smooth transition from theory to practice in healthcare environments. When used effectively, these tools can enhance patient outcomes and contribute to improved safety standards across settings.

The development process for this toolkit was informed by a targeted search using key terms such as “fall prevention,” “patient safety,” “risk assessment,” “root cause analysis,” and “evidence-based nursing practice.” These keywords guided the literature review and selection of tools that are directly applicable to the workflows of clinical nursing practice. The final compilation is structured to help nurses and health administrators translate research into practical, day-to-day applications that support patient safety and reduce fall incidents.

Moreover, the tools are designed to be utilized in diverse clinical scenarios, including staff training sessions, shift handovers, and quality improvement (QI) projects. Each item in the toolkit has been tailored to suit specific care settings—ranging from acute inpatient facilities to home healthcare environments and rehabilitation centers. This versatility ensures the strategies provided are adaptable, contextually appropriate, and sustainable, empowering nurses to lead fall prevention efforts effectively.

Annotated Bibliography

Category	Summary of Key Resource	Practice Application
Organizational Safety and Fall Prevention	Garcia et al. (2021) explored how nurses perceive fall prevention strategies, emphasizing the effectiveness of multifactorial programs that integrate environmental changes and patient education. Barriers included time limitations and lack of institutional support.	Useful during staff education and planning, this resource guides nurse leaders in addressing systemic barriers and improving staff engagement with fall prevention protocols.
	Linnerud et al. (2023) introduced a co-created strategy for fall prevention in home-care settings, developed with input from multiple stakeholders. The focus was on creating community-specific plans.	Supports collaboration and stakeholder engagement, making it ideal for QI teams aiming to design sustainable fall prevention models in home-care environments.
	Mulfiyanti & Satriana (2022) discussed the use of the SBAR method to enhance communication during nursing handovers, leading to improved patient safety and a reduction in fall rates.	Promotes reliable communication during shift changes. Nurses can apply SBAR to minimize fall risks through more structured and confident information exchanges.
Environmental Risk Reduction & Safety Assessment	Campani et al. (2021) assessed environmental risks in elderly care, providing strategies to identify hazards such as inadequate lighting or clutter. These assessments serve both community and institutional settings.	Nurses can utilize this tool during discharge planning and safety assessments, helping identify and mitigate risks in both home and hospital environments.
	Locklear et al. (2024) performed a narrative review on fall epidemiology and advocated for early risk assessments using tools like the Morse Fall Scale. Cost savings and outcome improvements were evident.	Ideal for staff training and risk evaluation, especially during patient admissions. It reinforces the importance of structured assessments in reducing costs and improving outcomes.
	Stathopoulos et al. (2021) identified overcrowded wards and suboptimal hospital layouts as key contributors to in-patient falls. The findings pointed to higher fall rates in neurology and orthopedic units.	Provides data for administrative planning. Nurse managers can use this evidence to advocate for better design and appropriate staffing levels in high-risk units.
Staff Education & Patient-Centered Strategies	Albertini et al. (2022) detailed a best-practice model using person-centered care to prevent falls in Brazilian hospitals. The model demonstrated that individualized approaches improved compliance with fall prevention protocols.	Encourages implementation of customized patient education strategies. It supports collaboration between staff and patients, especially in units dealing with elderly or high-risk populations.

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., … & 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, Publish Ahead of Print(3). https://doi.org/10.1097/ncq.0000000000000605

Heng, H., Jazayeri, D., Shaw, L., Kiegaldie, D., Hill, A.-M., & Morris, M. E. (2020). Hospital falls prevention with patient education: A scoping review. BMC Geriatrics, 20(1), 1–12. https://doi.org/10.1186/s12877-020-01515-w

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Heng, H., Kiegaldie, D., Shaw, L., Jazayeri, D., Hill, A.-M., & Morris, M. E. (2022). Implementing patient falls education in hospitals: A mixed-methods trial. Healthcare, 10(7), 1298. https://doi.org/10.3390/healthcare10071298

Lakbala, P., Bordbar, N., & Fakhri, Y. (2024). Root cause analysis and strategies for reducing falls among in-patients in healthcare facilities: A narrative review. Health Science Reports, 7(7). https://doi.org/10.1002/hsr2.2216

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., … & 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

Miura, T., & Kanoya, Y. (2025). Fall risk assessment and prevention strategies in nursing homes: A narrative review. Healthcare, 13(4), 357–357. https://doi.org/10.3390/healthcare13040357

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

Ruiz, J. F.-B., Chaparro, J. D., Romero, M. J. S., Molina, F. J. V., García, X. del T., Peño, C. B., … & López, J. C. (2022). Bedtime monitoring for fall detection and prevention in older adults. International Journal of Environmental Research and Public Health, 19(12), 7139. https://doi.org/10.3390/ijerph19127139