Implementing A Multi-Faceted Approach to Reduce Falls And Enhance Safety In Psychiatric Patients While Improving Nurses Perception While Improving Nurses Perception Of Fall Risk Identification

Purpose: The goal of this quality improvement project was to decrease falls in inpatient psychiatric units by at least 5% within six months, utilizing a multifaceted approach while increasing nurses' ability to identify patients at risk for falls. This project incorporated fall risk assessment, staff education, visual identifiers, and debriefings. Nurse confidence was measured post-intervention using a Likert scale survey. Background: Psychiatric fall rates range from 13 to 25 per 1,000 hospital days, compared to 3 to 4 in general hospitals. These rates highlight the importance of tailored interventions. This project was completed in an inpatient psychiatric facility in Southeastern Texas. Methodology: The Plan-Do-Study-Act (PDSA), Define-Measure-Analyze-Improve (DMAIC) model, and Donabedian Model for Quality Care guided this project through staff education, visual identifiers, audits, debriefs, and a tailored fall risk assessment. Outcomes measured included protocol adherence, fall incidence, and nurses' confidence using post-intervention Likert survey. Results: Patient falls decreased by 33.3% across two combined units, surpassing the 5% goal. Staff adherence rose from 85% to 100 % post-intervention surveys showed increased nurse confidence in identifying fall-risk patients (average score: 4.1/5). Implications: This project demonstrated that strategies tailored to psychiatric patients can reduce falls and strengthen staff confidence. Expansion to additional psychiatric facilities and continued evaluation are recommended. Limitations include single-site implementation and varying levels of staff engagement, which may affect generalizability.