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Course Name
Clinical Improvement Project II CAPSTONE
Graduation Year
2026
Faculty Advisor
Dr. Michelle Dang
Abstract
Inpatient falls are a major patient safety concern, particularly in orthopedic units where mobility limitations, comorbidities, and postoperative factors elevate risk and contribute to preventable injury, longer hospital stays, and increased costs. At Sutter Medical Center Sacramento’s orthopedic unit, an annual rate of 16 falls and persistent gaps in patient and staff education highlight the need for a targeted quality improvement initiative despite use of an EPIC predictive fall-risk model. Guided by the Plan-Do-Study-Act framework, this project implements a comprehensive fall-prevention education program modeled on the Fall T.I.P.S. toolkit, including a standardized bedside brochure, visual cues (wristbands, door signage, bedside cards), and structured nursing workflows to enhance individualized risk communication and shared responsibility among staff, patients, and families. The primary aim is to reduce inpatient falls by 15–20% (2–4 fewer falls per year) by August 2026 through improved fall-prevention knowledge, consistent documentation, and stronger engagement of nursing staff, charge nurses, leaders, and caregivers in safety practices. Process and outcome measures will include fall incidence, staff compliance with fall-risk assessments and education checklists, documentation of patient and family teaching in the electronic health record, and staff surveys on perceived barriers and brochure effectiveness to inform iterative PDSA cycles and sustain improvements in fall prevention on the orthopedic unit.
Recommended Citation
Chan, Kaitlyn; Garcia, Amparo Guzman; and Huynh, Tran, "Patient-centered Education in Fall Risk and Prevention Decreases the Number of Falls on the Orthopedic Unit" (2026). ELMSN E-Portfolio. A collection of Scholarly and Creative Works. 42.
https://scholarlycommons.pacific.edu/nursing-portfolios/42
