Enhancing Patient Safety: Embedding Fall Risk Assessment Learning Strategies into Nursing Orientation on an Adult Inpatient Behavioral Health Unit 140 views

Background: The Agency for Healthcare Research and Quality (AHRQ) estimates that between 700,000 to one million inpatient falls occur annually. Patients hospitalized on psychiatric units may be at increased fall risk related to psychiatric diagnoses, side effects of psychotropic medications, and the ambulatory environment (Turner et al., 2020; Chang & Jen, 2023). Purpose: The purpose of this project was to evaluate whether embedding learning strategies within the Tiered Skills Acquisition Model (TSAM) of nursing orientation improves registered nurse (RN) knowledge of effects of psychotropic medications that contribute to fall risk and confidence in recognition of medication effects that pre-empt a fall. Methods: This project was implemented on a 20 bed adult inpatient behavioral health unit (BHU) within a university health system. Fall prevention practices relevant to this setting were identified through a review of the literature. Unit specific knowledge gaps surrounding fall risk assessment were identified. “Think it Out, Talk it Out” cards (adapted from Mayo Clinic design) and case study aligned with TSAM focused on psychotropic medication-related fall risk were tested with new graduate nurses (NGN) and RNs new to the unit. Results: Self-perception of knowledge regarding effects of psychotropic medications improved for all survey respondents. Self-reported confidence in ability to recognize medication side effects that may pre-empt a fall improved for all survey respondents. Conclusion: Embedding learning strategies focused on fall prevention that align with TSAM have potential to improve safety practices related to fall risk assessment. The Think It Out, Talk It Out cards and case study represent adaptable, interactive learning tools that can be modified for additional clinical topics where knowledge gaps or skill development needs are identified.

DNP (Doctor of Nursing Practice)

fall prevention; fall risk; behavioral health; psychotropic medication; nursing orientation

English

All rights reserved by the author (no additional license for public reuse)

2026-04-30