Peer responses

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For patients 18 years and older on a medical-surgical unit, what is the impact of implementing the AHRQ’s Fall TIPS Toolkit, compared to current practice, on patient fall rate over 8-10 weeks?

What are the implications of the DNP Project (or Integrative Review) on nursing and/or healthcare outcomes? 

According to Dykes et al. (2017), patient falls are a communication problem. The implications on nursing practice and healthcare outcomes consist of (1) enhancing communication among staff, patients, and family members, (2) engaging patients and family, and (3) tailoring interventions (Dykes et al., 2019). The AHRQ’s Fall TIPS Toolkit consists of a three-step process, including conducting a fall risk assessment, identifying the patient-specific intervention based on the patient’s fall risk, and consistently adhering to the planned intervention (Duckworth et al. 2019). The literature review revealed nurses conducted the fall risk assessment but failed to verbally communicate the findings to staff, the patient, or family members. The critical component to preventing patient falls is the direct collaboration of the bedside nurse with the patient and family and effective communication. 


Duckworth, M., Adelman, J., Belategui, K., Feliciano, Z., Jackson, E., Khasnabish, S., Lehman, I.-F. S., Lindros, M. E., Mortimer, H., Ryan, K., Scanlan, M., Berger Spivack, L., Yu, S. P., Bates, D. W., & Dykes, P. C. (2019). Assessing the effectiveness of engaging patients and their families in the three-step fall prevention process across modalities of an evidence-based fall prevention toolkit: An implementation science study. Journal of Medical Internet Research, 21(1), (Links to an external site.)

Dykes, P. C., Adelman, J. S., Alfieri, L., Bogaisky, M., Carroll, D., Carter, E., Duckworth, M., Erickson, J. R. I., Flaherty, L. M., Hurley, A. C., Jackson, E., Khasnabish, S., Lindros, M. E., Manzano, W., Scanlan, M., & Spivack, L. B. (2019). The fall TIPS (Tailoring Interventions for Patient Safety) program: A collaboration to end the persistent problem of patient falls. Nurse Leader, 17(4), 365–370. (Links to an external site.)

Dykes, P. C., Duckworth, M., Cunningham, S., Dubois, S., Driscoll, M., Feliciano, Z., Ferrazzi, M., Fevrin, F. E., Lyons, S., Lindros, M. E., Monahan, A., Paley, M. M., Jean-Pierre, S., & Scanlan, M. (2017). Pilot testing fall TIPS (Tailoring Interventions for Patient Safety): A patient-centered fall prevention toolkit. Joint Commission Journal on Quality and Patient Safety, 43(8), 403–413.

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