Randa Kucey

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Background: Falls are an important safety concern among the elderly. A practice change project to decrease falls in the elderly population was implemented in a Patient-Centered Medical Home (PCMH) setting in Oregon with the purpose to determine whether staff was satisfied with the change effort. This endeavor encompassed two other clinics in a broader system which also embraced the change initiative.

Methods: An electronic survey was offered to staff over a two week period to assess their satisfaction with the implementation of the tools used to screen the elderly for falls with those at risk receiving appropriate interventions. The Hendrich II was chosen to determine fall risk; the Falls Prevention Action Guide for Providers (FPAGFP) guided implementations for those susceptible to falls. The University of Portland (UP) institutional review board (IRB) approved this project.

Results: Of the 20 respondents who completed the surveys, 14 were providers and residents, and 6 were MAs. All staff valued assessing the elderly for fall risk in clinical practice. All but one of the MAs indicated it was easy/very easy to incorporate use of the Hendrich II into their workflow. The majority of the providers indicated the tools were beneficial to help reduce falls in the elderly. No correlation existed between providers who believed in the effectiveness of the use of the FPAGFP to guide their actions to reduce falls and the belief that using the tool took time away from the patient encounter.

Conclusion: This practice change project was beneficial in that it identified the majority of elderly at risk for falling and provided strategies for providers to choose to reduce the risk. Analyzing survey results for change endeavors is a helpful step to determine if there are apparent trends in responses. Focused group discussions may aid in the identification of reasons for suboptimal screening and implementation practices with direction provided for ways to improve them. Providers and MAs who are using the tools effectively could be mentors for those who are struggling to implement them into their daily practice.


Patients--Safety measures; Medical care--Quality control; Nursing--Study and teaching

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NRS 597: Practice Improvement Project

Document Type

Doctoral Project

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Nursing Commons