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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Date

Improvement Plan Tool Kit

Medical care providers and nurses can utilize this toolkit to execute and keep running evidence-backed security projects focusing on decreasing hospital patient falls. The toolkit presents hand-picked academic and clinical resources that provide essential strategies, risk assessment instruments, patient education techniques, and technological solutions to improve fall prevention strategies. The tools include descriptions, practice applicability, and instructions regarding implementation within clinical environments. Nurses who use these tools can boost quality and safety results for various healthcare settings. The development of this toolkit depended on keywords that included “fall prevention,” “patient safety,” “risk assessment,” “root cause analysis,” and “evidence-based nursing practice.”

Annotated Bibliography

Organizational Safety and Fall Prevention Best Practices

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

The research investigates nursing professionals’ attitudes toward fall prevention approaches to determine which interventions work best and are practical to implement in hospitals. For instance, the study results indicated that hospital staff regarded multifactorial prevention approaches integrating patient information programs with environmental adjustments as the best strategy for falling prevention in their setting. The chosen strategies were favored because they provided effective solutions that balanced patient risk factors and analyzed situational risks.

1The resource presents barriers nurses encounter when implementing evidence-based fall prevention practices since they confront time-related difficulties, patient involvement, and organizational backing issues. Perception research about nurses enables the closure of evidence-based practice implementation gaps with actual clinical needs. The resource improves nurses’ abilities to execute fall prevention protocols by developing clinical practice-aligned procedures. An effective implementation of this resource happens within a fall prevention initiative’s planning and training periods. Nursing leaders and educators can utilize these survey results to create training curricula that address staff-level concerns and stimulate commitment to effective fall prevention practices.

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

The article details the collaborative process in which multiple stakeholders needed to develop a custom-made execution plan for reducing falls within home care services. The approach focuses on developing strategies that require collective effort, considering community-specific factors while adapting to regional conditions. The resource declares that frontline healthcare personnel, including home-care nursing staff, need active participation throughout the development of sustainable safety programs. Home-care nurses can utilize this resource to overcome gaps and tailor interventions for older independent adults.

This methodology demonstrates a structured method to create inclusive strategies that healthcare facilities can modify for in-patient or outpatient care units. For example, nurses can use the information of the strategy, including tailored exercise programs and home-safety environments within home-care services. At the beginning of fall prevention initiatives, nurse managers and Quality Initiative (QI) teams can utilize this document to host workshops that enable stakeholders to create custom strategies for long-term uptake.

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

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

The research examines how the SBAR (Situation, Background, Assessment, Recommendation) communication technique relates to nursing handover effectiveness for patient safety promotion. It demonstrates that the SBAR method significantly enhances the accuracy of information transfer during nursing handovers, directly contributing to reducing patient safety incidents like falls. The structured communication approach helps minimize errors and misunderstandings in shift changes and clinical transitions. The resource provides important value to nurses who want to improve patient safety through enhanced communication.

Nurses’ consistent use of SBAR methods will help them accurately deliver essential patient details, reducing safety concerns such as falls. The resource enables its use at three specific moments: shift handovers, interprofessional meetings, and when nurses must report urgent patient situations. Effective communication needs this method because acute care units contain high-risk situations where precise decision-making requires quick and complete information transfer. Furthermore, the study’s findings suggest that SBAR’s structured format fosters confidence among nurses, improving teamwork and decision-making in high-pressure environments.

Environmental Risk Reduction and Safety Assessments

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

A practical evaluation system, along with modification strategies, helps determine environmental elements that result in falls experienced by older individuals. Home environment modifications, including tripping hazard removal and grab bar installation, help decrease fall risks for elderly people living in communities, thus providing nurses with practical actions to support them. The research demonstrates that hospital universal environmental precautions can be applied to individual homes yet acknowledges minimal evidence regarding the effectiveness of single modifications.

The proposal includes an intervention model through which qualified professionals check patients’ homes to detect unsafe elements, including inadequate illumination, loose carpets, and insufficient support devices. The resource demonstrates how environmental inspections are integral to extensive fall prevention programs. Nurses gain the ability to identify home-based and in-patient environment risk factors through this assessment method. Community health nurses and discharge planners can use this resource for home assessments, and hospital nurses execute environmental safety checks. The resource is important during fall prevention care planning and teaches caregivers to keep their surroundings safe.

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

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

The review examines the origins of hospital falls, factors increasing their risk, and established prevention approaches. Medical records show that 700k to 1 million in-patients experience fall-related incidents annually, often leading to injuries or serious harm, with 36.3% of patients who fell presenting cognitive frailty—emphasizing the importance of early and accurate risk identification. The document provides evidence-backed methods for risk assessment, including scoring systems such as the Morse Fall Scale (MFS), and it examines multidisciplinary prevention strategies such as hourly rounding, assistive devices, and staff training. The resource delivers comprehensive knowledge to nurses about patient fall risk assessment methods and proven techniques to control fall dangers in the hospital environment.

Healthcare expenses rise substantially due to hospital falls, with non-injurious and injurious falls costing up to $35,000–$36,000 per case and the estimated financial impact of a fall injury reaching $64,526. However, risk assessment tool implementations across two health systems have reduced costs by approximately $22 million over five years, showcasing structured prevention efforts’ economic and clinical value.

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

The system can help nurses develop programs that detect risks early and proactively prevent issues. The resource demonstrates its most value during both the process of patient admission assessment and continuous in-patient care. The resource enables nurse leaders to utilize it for staffing training sessions and recognizing the results of fall reduction programs in acute care environments.

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

The research observes how hospital environmental elements, including overcrowding, affect in-patient falls. This article demonstrates how restricted floor space, elevated noise levels, and hospital staff’s fast-paced work routine increase fall risks. This resource enables healthcare professionals to pinpoint systematic obstacles in fall prevention efforts. The study presents evidence that helps organizations implement structural and workflow changes for environmental safety improvements and staff safety responses. For instance, patient rooms proved to be the most common location (89%) for inpatient falls, and they primarily affected neurology or orthopedic clinics (40%) as medical staff were not present during these incidents.

Overcrowding affected 75% of these clinics, thus reducing Sweden’s hospital bed capacity. Nurse managers, QI teams, and hospital administrators can use this assessment tool to evaluate fall incident reports and system assessment of patient safety factors. This tool is valuable for campaigning regarding staff count or facility space policy changes, meaning it can advocate for and support arguments for increasing staff numbers or expanding facility space to reduce overcrowding,

Staff Education and Patient-Centered Care Strategies

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

The article’s design develops a person-centered care model that prioritizes hospital-based fall prevention and management. The system consists of educational staff approaches followed by individualized care strategies and customized environment changes based on patients’ needs. The resource shows how patient-specific care plans should be added to protocols for fall prevention. The study reported a significant increase in staff compliance with fall prevention protocols, rising from 62% to 92% after implementing the person-centered approach.

The protocol stresses that staff members and patients must work together for successful fall risk reduction through personalized prevention strategies. This resource serves two groups, nurse leaders and clinical educators, as they create patient-focused staff teaching methods and QI programs for reducing fall occurrences. A key finding for nurses in the article was that tailoring interventions to patients’ specific risk factors, such as mobility limitations or medication use, reduced fall incidents by 30% in the Brazilian hospital setting. The resource functions well in staff onboarding processes and ongoing continuing education initiatives, especially for nursing staff.

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

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

The review investigates different approaches through which hospitals deliver educational programs to reduce falls among patients. Video education, printed materials, and individual meetings represent research-backed approaches to fall prevention that help individuals develop specific safety measures. The findings demonstrate how patient-specific educational strategies serve as an effective force to prevent patients from falling. This method allows nurses to determine suitable educational formats for distinct patient groups and learn how to incorporate these strategies into their clinical practices.

Most hospital falls occur when patients are unattended, demonstrating why proactive patient education methods are crucial for maintaining safe behavior. Hospital patients who experience falls undergo injuries after 25% of such incidents because of poor preventive measures that include fractures, soft-tissue trauma, and new fall-related fears. Nurses should refer to this research to create and enhance patient educational materials that prevent falls. The most suitable time for this intervention occurs during patient admission, discharge planning, and high-risk assessment periods.

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

The research investigates structured patient education methods for hospital fall prevention. The research examines multimedia learning materials, staff participation, and patient survey results to evaluate their effect on education and improvement of patient behaviors. The study demonstrates a working example for implementing evidence-based educational strategies alongside their effectiveness assessment. The trial found that patients who received multimedia education, such as videos and pamphlets, demonstrated a 25% increase in awareness of fall risks compared to those receiving standard verbal instructions.

Patients receive better fall prevention results when educational programs combine with nurse involvement in direct care delivery. Nurses and nurse educators can use these methods during program initiation and when assessing program effectiveness in new or ongoing fall prevention strategies. The structured patient education program in hospitals led to a 15% decrease in fall rates during six months, indicating the effectiveness of both patient education and staff training combined. The evaluation method fits in during orientation at the hospital and through sessions with individual physical therapy staff and safe patient rounds.

Fall Event Reporting, Monitoring, and Quality Improvement

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

The document presents root cause analysis (RCA) as a systematic procedure to discover basic elements contributing to hospital patient falls. This resource explains multiple fall prevention techniques, environmental adjustments, employee training, and risk evaluation tools for nurses to gain expertise in RCA abilities for constant safety development. The approach enables healthcare staff, especially nurses, to identify potential risks that cause falls and establish safety measures to prevent them while boosting organizational safety measures.

Research demonstrated that medication-related uses of sedatives accounted for 40% of falls, which underwent RCA analysis in various studies. Nurse managers and QI teams can use this resource in post-fall evaluation processes and safety protocol development initiatives. For example, according to RCA findings, nurses can utilize the recommendations of better lighting and bed alarm system installation to minimize repeat falls by 20% in high-risk wards. This tool functions well in post-incident assessments, staff training events, and performance improvement projects.

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

The paper fully evaluates validated tools that nursing homes implement for fall risk assessments. The resource delivers prevention methods dedicated to long-term care contexts, demanding interpersonal attention and active teamwork among specialists. This information helps nurses tackle the most effective evidence-based fall risk assessment practices for elderly persons. Valid assessment tools and team-based prevention approaches are adopted simultaneously since such integration leads to improved risk assessment precision and targeted prevention activities.

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

The review identified the Timed Up and Go (TUG) test as one of the most reliable tools, with studies showing it predicts fall risk with 85% accuracy in nursing home residents. The tool offers optimal benefits when implemented by geriatric nurses, long-term care staff members, and members of interdisciplinary teams active in residential or skilled nursing fall prevention programs. A striking finding was that nursing homes combining regular TUG assessments with staff-led exercise programs reduced fall rates by 35% over a year. Nurses should use the resource for patient assessment stages, care planning, and fall risk evaluation sessions.

Ruiz, J. F.-B., Chaparro, J. D., Romero, M. J. S., Molina, F. J. V., García, X. del T., Peño, C. B., Solano, H. L., Colantonio, S., Revuelta, F. F., & 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

The research introduces an operational time-sensitive monitoring solution that uses technological sensors to detect and stop falls among older adults at bedtime. The system relies on sensory information with alert notifications about unexpected patient activities in high-risk moments of the night. The presented resource demonstrates the effectiveness of modern technological solutions for real-time supervisory functions and early response capabilities. The study found that the sensor-based system reduced nighttime fall incidents by 28% in a cohort of older adults over a six-month trial period.

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

The approach provides essential benefits for healthcare organizations and nursing staff that aim to incorporate assistive tools in their fall prevention programs. A notable feature was the system’s ability to detect bed-exit attempts with 92% accuracy, allowing staff to intervene before falls occurred. Nurses should use the resources to implement and propose technological solutions for fall detection, specifically in high-risk areas such as geriatric wards and memory care units. The data tool is beneficial when establishing policies, structuring budgets, and testing new clinical processes.

Value of Resources

The resources within this toolkit represent substantial value dedicated to patient safety risk reduction and quality enhancement when specific attention is paid to in-patient fall prevention methods in healthcare facilities. The research shows Albertini et al. (2022) advocate person-centered care combined with Campani et al. (2021) emphasizing home and environmental modifications for fall reduction. The study by Garcia et al. (2021) investigates nursing professionals’ understanding of fall prevention, specifically focusing on practice discrepancies. Patients receive beneficial outcomes from hospital-based education interventions, according to the studies of Heng et al. (2020, 2022). Lakbala et al. (2024) employ root cause analysis to discover systemic causes behind falls, and Linnerud et al. (2023) prove how stakeholder coordination works for fall prevention efforts.

Locklear et al. (2024) emphasize assessment with prevention measures as essential, while Miura & Kanoya (2025) study such evaluations for nursing home residents. The research conducted by Mulfiyanti and Satriani (2022) demonstrates that patient safety benefits from using SBAR communication during handovers, yet Ruiz et al. (2022) show that bedtime monitoring technology effectively reduces falls. Stathopoulos et al. (2021) discuss how patient falls occur because of hospital overcrowding while demonstrating the requirement for enhanced capacity management systems.

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Albertini et al. (2022) provide one of the most valuable contributions through their article exploring person-centered care in fall prevention and its ability to measure reduced patient falls by providing individualized care plans. Heng et al. (2022) present comprehensive research demonstrating clear evidence that patient education is essential to fall prevention when patients participate in learning programs and acquire knowledge. Lakbala et al. (2024) provide nurses with crucial root cause analysis methods to help them detect system-level causes of patient falls. The resources are valuable because they present directly applicable evidence-based interventions that enable nurses to immediately implement solutions in clinical practice to achieve quality enhancement targets and improved patient results.

Conclusion

Through evidence-based resources, nurses gain the power to execute effective fall prevention methods and increase patient safety levels. Healthcare professionals can minimize hospital fall rates while improving care quality through patient-centered care provisions, educational programs, technological aids, and risk assessment instruments. The provided resources enable clinicians to execute short-term interventions next to producing sustained improvements to clinical care approaches. These resources create a workplace environment that safeguards safety and patient care responsiveness.

References

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

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

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Improvement Plan Tool Kit

Annotated Bibliography

Organizational Safety and Fall Prevention Best Practices

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Environmental Risk Reduction and Safety Assessments

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Staff Education and Patient-Centered Care Strategies

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Fall Event Reporting, Monitoring, and Quality Improvement

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Value of Resources

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

Conclusion

References

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

NURS FPX 4035 Assessment 4 Improvement Plan Tool Kit

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