Abstract
Patient falls continue to occur in the hospital setting despite staff education and comprehensive fall protocols. The AHRQ estimates 700,000 to 1,000,000 hospitalized patients experience a fall annually. Nurses are compassionate professionals who strive to protect their patients and ensure they receive safe care, but are there factors preventing adherence to their unit fall protocols? The PICOT question for this process improvement initiative was how does the use of a nudge intervention in an adult inpatient acute care unit compared to no nudge intervention affect nursing adherence to fall policy over a three-month time period? An 8.5 x 11 nudge poster with the tag line “Don’t forget to connect” and easy to interpret graphics was implemented in a 38-bed acute care medical-surgical unit. By ensuring the smart beds were properly connected, the nurses would be adhering to the hospital fall protocol of correctly utilizing the breakaway bed cables. Prior to the intervention only 50% of the beds were properly connected compared to 80% afterwards. The patient fall rate was at seven before the intervention and dropped to one after the three-month implementation, which reflects an 85% decrease in patient falls. It cannot be determined to what extent the nudge poster contributed to increased fall protocol adherence, or the reduction in the fall rate. The nudge poster is an inexpensive and easy to implement intervention that can be replicated in any unit and causes no disruption to patient care or staff workflows.
Date of publication
Summer 8-2026
Document Type
DNP Scholarly Project
Language
english
Persistent identifier
http://hdl.handle.net/10950/5125
Committee members
Gina Nickels-Nelson DNP APRN, FNP-BC, ACUE
Degree
Doctor of Nursing Practice
Recommended Citation
Wysocki, Mary Regina, "DNP Final Report: Plug in to Prevent Falls: A Nudge-Based Approach to Bed-Nurse Connectivity and Protocol Adherence" (2026). DNP Final Reports. Paper 103.
http://hdl.handle.net/10950/5125