Date of Degree


Document Type

Doctoral Project

Degree Name

Doctor of Nursing Practice (DNP)




Diana Beckmann-Mendez


Background. Falls are the most reported incidents in the hospital setting, especially among older adults. According to the National Database of Nursing Quality Indicators (NDNQI), the number of falls in inpatient psychiatric units is 13-25 per 1,000 patient days, compared to 4 per 1,000 days for medical-surgical units. This DNP project aims to implement an interprofessional fall risk team to reduce falls in an older adult inpatient psychiatric unit. Problem. The psychiatric inpatient units had a total of 31 falls, with 13 (40%) occurring on the older adult unit. Interventions. Education of nursing staff, providers, and physical therapy (PT) was done on the Wilson Sims Fall Risk Assessment Tool. Providers were educated on high-risk fall scores and related medications. Screening for high-risk patients upon admission or status change was performed by nursing staff, and fall scores were discussed during interprofessional rounds. Medication review sheets were created for providers to record medication changes based on fall risk scores. PT consults are ordered in the electronic health record (EHR) upon admission. Results. During the first three quarters of 2021, there were a total of 19 falls on the inpatient psychiatric units, with 3 (16%) occurring on the older adult psychiatric unit. Implications for Practice. The outcomes of this QI project help expand on the dearth of literature regarding falls on psychiatric inpatient units. This project also highlights The Joint Commissions’ recommendation of establishing an interprofessional team, making fall prevention everyone’s responsibility by increasing awareness of fall risk patients and developing strategies for fall prevention.