Evaluating Fall Prevention Outcomes: Fall Rates, Staff Fall Knowledge, and Perceptions on Safety Culture

Practice Problem: The practice problem addressed in this project was the elevated fall rates on a 46-bed medical–surgical unit with a reported sentinel fall event, prompting the need to evaluate the current fall prevention program. PICOT: The PICOT question that guided this project was: In nursing staff on a medical–surgical unit (P), how does the implementation of an evidence-based fall prevention program evaluation using AHRQ tools (I), compared with no formal program evaluation (C), influence staff knowledge, perceptions of safety culture, and fall rates (O) over 8-weeks (T)? Evidence: Evidence supporting this project emphasized that structured staff education, strong communication, and consistent adherence to fall prevention measures are associated with reduced fall rates and improved safety culture perceptions. The CDC Program Evaluation Framework served as the primary structure for the evaluation. Intervention: The intervention included administering AHRQ Fall Knowledge Tests, the Hospital Survey on Patient Safety Culture (SOPS), conducting organizational assessments, and extracting fall data and fall audit data from organizational fall reports. Outcome: Results showed moderate fall prevention knowledge, generally positive perceptions of communication and teamwork, and strong engagement in safety processes. Statistical analyses showed no significant relationships between fall knowledge, safety perceptions, or demographic factors, while qualitative comments highlighted teamwork and staffing as key influences. Conclusion: This project revealed that staff knowledge, safety perceptions, and fall rates and prevention compliance do not always align, underscoring the importance of system-level strategies, ongoing education, and strengthened communication. Findings provide actionable insight for guiding future fall prevention and quality improvement initiatives.