evidence-based practice, fall prevention, inpatient, nursing, patient safety, performance improvement, risk assessment



  1. Gutierrez, Felipe RN, MSN, FNP
  2. Smith, Kevin RN


Fall prevention poses a major challenge to healthcare personnel. Fall prone patients must be accurately identified and staff must adhere to evidence-based practices that have distinct value for preventing falls. This article describes a Definitive Observation Unit (DOU) and its evidence-based fall-prevention protocol based on nationally recognized standards. Despite the adoption of the protocol, fall occurrence rates remained above California Nursing Outcomes Coalition benchmarks. There were variations among nurses, physicians and physical therapists in regard to the value of fall prevention program components such as pre-formatted orders, physical therapy referrals and documentation.


This authors report results of a study using an evidence-based practice (EBP) framework for evaluating an interdisciplinary, multifactorial fall prevention protocol. Results indicated that staff champions and resources are essential elements for changing practices that are vital to fall reduction.