NURS FPX 6212 Assessment 4 Planning for Change: A Leader’s Vision
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Planning for Change: A Leader’s Vision Medication errors (MEs) continue to pose a serious challenge at Mercy General Hospital (MGH), affecting patient safety, care quality, and overall operational efficiency. To address this issue, it is essential to implement a strategic plan that refines institutional workflows, enhances staff practices, and optimizes system functionality. By focusing on minimizing MEs, the organization can reduce adverse patient outcomes, foster a culture of safety, and support continuous quality improvement initiatives. This vision requires coordinated leadership, robust training, and the adoption of advanced technological tools to ensure safe and effective medication administration. Presentation Objectives The objectives of this plan include: Organizational Problem Medication errors at MGH occur at a rate of 40 per 1,000 patient days, posing a severe risk to patient safety, care standards, and institutional credibility. Factors contributing to this problem include a high patient influx, which strains staff capacity, and complex treatment regimens for patients with multiple chronic conditions, which increase the likelihood of dosage errors and adverse drug interactions (Tariq et al., 2024). Additionally, workforce shortages and excessive workloads amplify fatigue, miscommunication, and inconsistent protocol adherence. The consequences of MEs are significant, ranging from patient harm and extended hospital stays to increased healthcare costs and diminished public trust. In the United States, preventable medication-related adverse events account for 44,000 to 98,000 hospital deaths annually, exceeding fatalities from motor vehicle accidents (Tariq et al., 2024). Beyond patient safety, MEs also negatively affect staff well-being, increasing stress and reducing job satisfaction. Addressing these systemic challenges is crucial to cultivating a culture of safety and improving patient outcomes. Comprehensive Quality and Safety Plan Enhancing Medication Safety with BCMA MGH plans to implement an advanced Barcode Medication Administration (BCMA) system to reduce MEs. This technology verifies patient identity, medication type, dosage, and timing, providing real-time support to clinicians to prevent errors (Tariq et al., 2024). Successful implementation requires clear policies promoting BCMA use and comprehensive staff training to ensure proper adoption. Standardizing safety protocols through BCMA will enhance both medication safety and accurate patient data management. Integration of EHRs with Decision-Support Tools Electronic Health Records (EHRs) integrated with clinical decision-support systems can mitigate MEs by offering real-time alerts for potential drug interactions, adverse reactions, and dosage issues. These tools empower staff to make well-informed decisions (Tariq et al., 2024). Policies promoting optimal EHR use, combined with robust staff training, are essential to standardize workflows, provide immediate access to critical information, and reduce preventable medication errors. Standardized Handoff Communication Protocols Structured communication tools, such as SBAR (Situation, Background, Assessment, Recommendation), can improve the accuracy of information transfer during patient handoffs, reducing the likelihood of medication errors (Bindra et al., 2021). Ongoing training, simulation exercises, and performance evaluations ensure that staff develop effective communication skills. This structured approach fosters safer patient care, minimizes miscommunication, and strengthens a culture of safety. Existing Organizational Functions, Processes, and Behaviors Several organizational factors at MGH contribute to MEs, including high patient volumes, complex medication regimens, excessive workloads, and insufficient staffing. Poorly coordinated handoffs and inefficient communication channels increase the likelihood of errors (Bindra et al., 2021). Additionally, the absence of integrated EHRs with decision-support capabilities limits real-time access to critical alerts, while insufficient staff training prevents consistent adherence to best practices (Lou et al., 2022). Without BCMA, manual verification processes heighten the risk of adverse drug events. Organizational culture also plays a pivotal role: a culture that promotes transparency, accountability, and collaboration encourages staff to report errors and near misses, facilitating systemic improvements (Tariq et al., 2024). Conversely, high-pressure environments with limited procedural support lead to protocol non-compliance, perpetuating safety risks. Current Outcome Measures At MGH, progress in reducing MEs will be evaluated using three primary indicators: Indicator Description Advantages Limitations Medication Error Rate Quantifies the number of MEs per 1,000 patient days Objective, measurable, tracks trends May miss near misses; does not identify root causes Patient Satisfaction Scores Reflects patient perception of care quality Indicates patient experience and perceived safety Subjective; influenced by external factors like wait times Staff Adherence Metrics Measures compliance with safety protocols Demonstrates procedural compliance Does not fully capture application under complex clinical conditions These metrics collectively provide insights into medication safety, staff performance, and patient experience, while also identifying areas for targeted improvement. Actionable Plan to Achieve Improved Outcomes Strategy Action Steps BCMA Implementation – Update policies to mandate BCMA use- Conduct audits to ensure compliance- Train staff on interactions, allergies, and dosage checks- Monitor potential MEs using BCMA alerts- Update BCMA system with latest clinical guidelines EHR Integration – Revise protocols to include decision-support tools- Train staff on identifying drug interactions and dosages- Strengthen data security measures- Implement alerts for potential errors- Continuously update platform with clinical best practices SBAR Communication – Apply SBAR in all handoffs- Integrate SBAR into onboarding and ongoing training- Conduct simulations and role-playing exercises- Document incidents using SBAR for analysis- Evaluate adherence and provide feedback Assumptions of the Plan The success of the plan depends on active staff engagement in training and proper use of technology, with leadership enforcing relevant policies. It assumes that BCMA and EHR systems function reliably and that staff consistently apply SBAR protocols. Adequate staffing and time allocation are also critical to ensure full adoption and sustained improvements. Future Vision and Nurse Leaders’ Role MGH aims to create a patient-centered culture that prioritizes safety while continuously improving clinical outcomes. Key objectives include enhancing BCMA and EHR functionality, standardizing staff communication, and strengthening education on patient safety (Nurmeksela et al., 2021). Nurse leaders play a critical role by guiding teams, promoting safety initiatives, and advocating for interprofessional collaboration. Effective leadership ensures adherence to protocols, encourages error reporting, and fosters continuous quality improvement (Tariq et al., 2024). By leveraging interdisciplinary teamwork, including physicians, pharmacists, and allied health professionals, nurse leaders drive measurable improvements in patient outcomes, satisfaction, and organizational resilience. A culture of transparency and teamwork strengthens the hospital’s capacity to address
NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Outcome Measures, Issues, and Opportunities Medication errors (MEs) have become a significant concern for quality and patient safety at Mercy General Hospital (MGH). According to the recent gap analysis, these errors are influenced by organizational structures, workflows, and operational practices. Examining these factors is critical to understanding patient outcomes and designing interventions that reduce risk. By assessing quality and safety metrics, MGH can implement actionable strategies that improve care delivery, ensure accountability through measurable results, and foster a culture of safety. Guided by a planned change framework, the hospital can strengthen information-sharing and enhance clinical outcomes. Analysis of High-Performing Organizations How do high-performing healthcare organizations reduce medication errors? High-performing healthcare institutions prioritize patient safety through operational efficiency, adherence to evidence-based protocols, and the promotion of safe practices. Key organizational elements include: Organizational Functions Description Communication Clear, structured, and frequent communication across teams to prevent errors. Personnel Training Ongoing education to ensure staff competency and adherence to protocols. Interdisciplinary Coordination Seamless collaboration among nurses, physicians, and pharmacists. Data Management Accurate tracking of medication administration and adverse events. Specific interventions such as medication administration checklists, Barcode Medication Administration (BCMA) systems, and standardized medication reconciliation have been shown to reduce MEs and improve workflow efficiency (Grailey et al., 2023). Additionally, fostering a culture of accountability, continuous education, and open reporting enables staff to disclose errors without fear of punishment. Leadership is essential in reinforcing communication and knowledge-sharing, creating an environment where safety is embedded into daily operations. These practices not only improve patient outcomes but also serve as benchmarks for addressing systemic challenges such as medication errors. What gaps remain in research regarding staff compliance and patient outcomes? Despite improvements in procedural standards and staff practices, gaps persist in understanding the direct link between compliance and outcomes. Areas requiring further exploration include: Enhanced data collection and stakeholder collaboration are necessary to refine strategies and increase the accuracy of quality assessments. Organizational Support for Outcome Measures What organizational factors influence medication errors at MGH? MGH’s patient safety and quality outcomes are shaped by multiple operational elements. Key performance indicators (KPIs) for MEs include error rates, patient satisfaction, and adherence to medication safety protocols. Effective leadership, collaboration, and communication are pivotal in reducing these errors. Research demonstrates that strong managerial engagement fosters a safety-oriented culture, improves staff expertise, and strengthens teamwork (Nurmeksela et al., 2021). Factor Role in Reducing MEs Leadership Encourages safety culture and accountability. Interdisciplinary Communication Ensures timely data exchange and error prevention. Reporting Systems Facilitates rapid detection and correction of issues. Technology (BCMA & EHR) Reduces human error and supports accurate dosing. Staff Engagement Enhances compliance and improves patient satisfaction. Innovative technologies such as BCMA and electronic health records (EHRs) enhance patient safety by verifying medication administration and standardizing medication reconciliation, particularly during care transitions (Grailey et al., 2023). Human factors, including engagement and accountability, remain critical in maintaining adherence to safety measures (Elliott et al., 2021). A culture that encourages error reporting and continuous improvement strengthens overall patient outcomes. Quality and Safety Outcomes and Proposed Measures What are MGH’s current performance metrics, and what improvements are targeted? Outcome Measure Current Value Target Medication Errors 40 per 1,000 patient days 20 per 1,000 patient days (60% reduction) Patient Satisfaction 80% 90% Compliance with Medication Safety Protocols 60% 80% To address performance gaps, MGH proposes several evidence-based initiatives: Ongoing staff development through training, workshops, and audits supports these initiatives, ensuring adherence to updated protocols. Reliable data collection through dashboards, patient surveys, and staff feedback is essential for monitoring progress. Addressing inconsistencies in reporting and standardizing data capture will improve the accuracy of MEs tracking and patient satisfaction assessments. Performance Issues and Opportunities in the Healthcare Setting What factors contribute to performance issues at MGH? Several factors contribute to MEs at MGH: These conditions increase the risk of dosing errors and reduce the time available for accurate medication administration. How can MGH improve medication process accuracy? Strategy Expected Outcome Optimize Staffing & Task Organization Reduces employee strain and enhances care quality. Integrate BCMA & EHR Reduces variability and improves accuracy in medication delivery. Standardize Communication Protocols Enhances handoff efficiency and reduces errors. Enhance Training Programs Fills knowledge gaps and ensures protocol adherence. Future research questions include: the causes of MEs in high-volume units, the impact of staffing shortages, the effectiveness of training programs, and the role of patient engagement in medication safety. Change Model for Outcome Measurement and Knowledge Sharing How can MGH systematically reduce medication errors? The Plan-Do-Study-Act (PDSA) model provides a structured framework for continuous improvement (Chen et al., 2020): Phase Actions at MGH Plan Set targets for MEs reduction, patient satisfaction, and compliance. Assess staffing, medication management, and communication needs. Do Pilot interventions including BCMA, EHR integration, SBAR handoffs, and staff training in controlled units. Study Evaluate outcomes through MEs frequency, patient satisfaction, and protocol adherence. Collect staff and patient feedback. Act Adjust protocols, training, and resources based on findings and implement improvements organization-wide. Structured knowledge sharing is achieved through workshops, training sessions, and clear communication channels. Feedback loops and interdisciplinary collaboration with nurses, pharmacists, physicians, and IT staff ensure that multiple perspectives guide implementation. This approach supports error reduction, knowledge transfer, and enhanced patient care throughout the project lifecycle. Conclusion Addressing medication errors at MGH requires a combination of evidence-based interventions, technology integration, and a safety-focused culture. Implementation of BCMA, EHR systems, standardized communication protocols, and comprehensive staff training will reduce errors and improve patient outcomes. Utilizing the PDSA framework will allow MGH to monitor progress, refine practices, and enhance knowledge sharing across teams. These initiatives strengthen operational efficiency, elevate care quality, and reinforce the hospital’s commitment to patient safety. References Chen, Y., VanderLaan, P. A., & Heher, Y. K. (2020). Using the model for improvement and Plan-Do-Study-Act to effect SMART change and advance quality. Cancer Cytopathology, 129(1), 9–14. https://doi.org/10.1002/cncy.22319 Elliott, R. A., Camacho, E., Jankovic, D., Sculpher, M. J., & Faria, R. (2021). Economic analysis of the prevalence and clinical and economic burden of medication error
NURS FPX 6212 Assessment 2 Executive Summary
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Executive Summary Inpatient falls remain a significant concern for patient safety and quality of care at Methodist University Hospital (MUH). These incidents often arise from gaps in preventive measures and inadequate monitoring. As a nurse leader, it is essential to evaluate and report on outcome metrics related to falls to guide effective interventions. This executive summary highlights the importance of tracking inpatient fall-related outcomes, examines strategies to reduce falls, and emphasizes the leadership role in implementing evidence-based improvements. Quality and Safety Outcome Measures Optimizing strategies to prevent inpatient falls at MUH is critical for enhancing patient safety and overall care quality. Implementing changes can reduce the frequency of falls, related injuries, hospital readmissions, and financial burdens. Outcome measures provide concrete indicators for assessing the effectiveness of interventions. Key metrics include fall rates, injury incidence, patient satisfaction, and cost savings. Fall Rates Fall rates are quantifiable metrics representing the frequency of falls per 1,000 patients or bed days over a defined period (AHRQ, 2024). They help identify trends, high-risk patient groups, and the success of fall prevention programs. Fall-Related Injuries Monitoring injuries resulting from falls provides insight into the effectiveness of safety interventions (AHRQ, 2024). For instance, evidence-based approaches reduced fall injuries at some facilities from 900 to 759 incidents (Dykes et al., 2023). Patient Satisfaction Patient perceptions regarding fall prevention impact engagement and confidence in safety practices. MUH currently reports a satisfaction score of 65% for fall prevention efforts. Cost of Falls Analyzing costs associated with inpatient falls helps quantify financial implications. Implementing fall prevention programs can save approximately $14,600 per 1,000 patient days (Dykes et al., 2023). Table 1. Outcome Measures for Inpatient Falls at MUH Outcome Measure Definition / Description Strengths Limitations Fall Rates Number of falls per 1,000 patients/bed days Detect patterns, evaluate interventions Requires accurate reporting; severity not reflected Fall-Related Injuries Incidents causing harm to patients from falls Direct measure of safety effectiveness Ignores near-misses and emotional impact Patient Satisfaction Patients’ perception of fall prevention efforts Provides actionable feedback Subjective; influenced by unrelated variables Cost of Falls Financial impact of falls and prevention programs Demonstrates economic benefits Excludes indirect or reputational costs Strategic Value of Outcome Measures Tracking outcome metrics provides MUH with actionable insights for strategic decision-making. Integrating these measures into a performance management framework ensures alignment with MUH’s strategic goals, supports continuous quality improvement, and prevents negative outcomes from being overlooked. The Relationship between Inpatient Falls and Outcome Measures Inpatient falls at MUH are systemic safety issues that directly affect patient outcomes and hospital performance. High fall rates often indicate gaps in safety protocols, increasing injury risk, lengthening hospital stays, and raising healthcare costs. Falls also negatively influence patient satisfaction, potentially reducing hospital credibility and patient volume. Financially, both injurious and non-injurious falls impose substantial costs, with reported expenses of $35,366 and $36,777 per 1000 patient days, respectively (Dykes et al., 2023). Environmental factors such as wet floors (11.9%) and unsafe equipment (13.4%) contribute to falls (Janse et al., 2020). Collecting detailed data on the time, location, patient behavior, and staff ratios can guide targeted interventions. Outcome Measures and Strategic Initiatives MUH’s fall prevention initiatives rely on structured, evidence-based practices: Target Goals for MUH Metric Current Level Goal Target Rationale Fall Rate 100% baseline Reduce by 60% Minimize patient injuries and improve safety Patient Satisfaction 65% 95% Enhance patient trust and engagement Cost Savings Baseline Increase by 85% Reduce financial burden from falls By monitoring these outcomes, MUH can implement focused interventions, track progress, and sustain high standards of patient safety. Leadership Role Nurse leaders play a pivotal role in implementing fall prevention strategies by promoting a culture of safety, allocating resources, and motivating staff. Effective communication of goals, regular training sessions, and engagement initiatives foster alignment and commitment across teams (Murray & Cope, 2021). Leaders should establish policies encouraging compliance with safety protocols, provide necessary prevention tools, and promote interdisciplinary collaboration. Creating a non-punitive environment encourages staff to report falls or near-misses, supporting continuous improvement (Gaur et al., 2021). Leadership thus directly influences patient outcomes, staff accountability, and the success of fall prevention initiatives. Conclusion Addressing inpatient falls at MUH requires a comprehensive strategy encompassing outcome measurement, strategic interventions, and strong leadership. Systematic monitoring of fall rates, injuries, patient satisfaction, and associated costs informs decision-making and enhances care quality. Leadership-driven initiatives, interdisciplinary collaboration, and targeted interventions foster a culture of safety, ultimately reducing fall incidents and improving patient outcomes. References AHRQ. (2024). How do you measure fall rates and fall prevention practices? Agency for Healthcare Research and Quality. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html Albertini, A. C. D. S., & Peduzzi, M. (2024). Interprofessional approach to fall prevention in hospital care. Revista da Escola de Enfermagem da USP, 58, e20230239. https://doi.org/10.1590/1980-220x-reeusp-2023-0239en Bernet, N. S., Everink, I. H., Jos MGA Schols, Ruud JG Halfens, Richter, D., & Hahn, S. (2022). Hospital performance comparison of inpatient fall rates; the impact of risk adjusting for patient-related factors: A multicentre cross-sectional survey. BioMed Central Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07638-7 DiGerolamo, K. A., & Chen-Lim, M. L. (2020). An educational intervention to improve staff collaboration and enhance knowledge of fall risk factors and prevention guidelines. Journal of Pediatric Nursing, 57, 43–49. https://doi.org/10.1016/j.pedn.2020.10.027 Dykes, P. C., Bowen, M., Lipsitz, S., Franz, C., Adelman, J., Adkison, L., & Bates, D. W. (2023). Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program. JAMA Health Forum, 4(1), e225125. https://doi.org/10.1001/jamahealthforum.2022.5125 NURS FPX 6212 Assessment 2 Executive Summary Gaur, S., Kumar, R., Gillespie, S. M., & Jump, R. L. P. (2021). Integrating principles of safety culture and just culture into nursing homes: Lessons from the pandemic. Journal of the American Medical Directors Association, 23(2), 241–246. https://doi.org/10.1016/j.jamda.2021.12.017 Janse, R., Anita, & Crowley, T. (2020). Factors influencing patient falls in a private hospital group in the Cape Metropole of the Western Cape. Health SA Gesondheid, 25, 1392. https://doi.org/10.4102/hsag.v25i0.1392 Murray, M., & Cope, V. (2021). Leadership: Patient safety depends on it! Collegian Journal of the Royal College of Nursing Australia, 28(6), 604–609. https://doi.org/10.1016/j.colegn.2021.07.004
NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis
Student Name Capella University NURS-FPX 6212 Health Care Quality and Safety Management Prof. Name Date Quality and Safety Gap Analysis Patient falls in hospital settings remain a significant concern for both safety and quality of care. Falls can result in physical injuries, psychological distress, extended hospital stays, and increased healthcare costs. This gap analysis focuses on Methodist University Hospital (MUH) to identify the key factors contributing to inpatient falls and provide evidence-based recommendations to enhance patient safety and overall care quality. Organizational Problems and Adverse Quality and Safety Outcomes What is the primary patient safety concern at MUH? The main issue at MUH is inpatient falls, which carry severe consequences for both patients and the healthcare system. Falls can lead to physical injuries such as fractures, intracranial trauma, heavy bleeding, and, in severe cases, death. They also impose financial strain on hospitals due to increased treatment costs and regulatory penalties (Ghosh et al., 2022; Turner et al., 2020). Psychologically, falls cause fear and anxiety in patients, reducing overall patient satisfaction. According to the Centers for Medicare and Medicaid Services (CMS), MUH reports a patient fall rate of 0.295 per 1000 admissions, below standard safety benchmarks (Leapfrog, 2024). Nationally, inpatient fall rates range from 1.7 to 16.9 per 1000 admissions, with moderate injuries occurring in 6.9–72.2% of cases and severe injuries in 0.8–30.1% (Ghosh et al., 2022). In the U.S., 6–27% of inpatient falls result in significant harm, with average hospitalization costs reaching $4,200 per fall-related injury. What factors contribute to patient falls? Patient falls are influenced by both internal and external factors: Factor Type Examples Patient-related Age, impaired mobility, cognitive decline, medication side effects Environmental Slippery floors, poor lighting, limited access to facilities, congested areas Organizational Staff shortages, inconsistent implementation of safety protocols Technological Lack of monitoring systems, insufficient fall detection devices Failure to address these issues increases hospital costs, prolongs stays, damages institutional reputation, and can result in CMS reimbursement losses (Turner et al., 2020). Furthermore, gaps exist in knowledge regarding the effectiveness of current fall prevention strategies and the role of innovative technologies in fall reduction at MUH. Practice Changes What practice changes can reduce patient falls at MUH? A recent internal review at MUH highlighted inconsistent fall risk assessments and insufficient prevention strategies as key contributors to falls. Recommended practice changes include: These practice changes aim to reduce fall incidents while enhancing patient safety and overall care quality. Prioritization of the Proposed Change Strategies Priority Proposed Strategy Rationale 1 Staff training Skilled staff can identify risks quickly and respond appropriately (Saki et al., 2023) 2 Standardized fall risk assessment Ensures early identification of high-risk patients and consistent care practices (Strini et al., 2021) 3 Interdisciplinary fall prevention team Promotes collaboration, thorough risk evaluation, and improved patient outcomes (Albertini & Peduzzi, 2024) 4 Environmental modifications Supports patients with balance or visual impairments and complements technological interventions (Turner et al., 2020) Staff training is the top priority because competent personnel are central to recognizing fall risks and applying effective interventions. Environmental changes, while necessary, are fourth in priority since technological solutions alone cannot replace human vigilance. Quality and Safety Culture and Its Evaluation How will the proposed changes enhance safety culture at MUH? Integrating these changes promotes a culture of safety by equipping staff with knowledge, fostering collaboration, and encouraging proactive risk management. Key measures include: Evaluation Metrics: Metric Purpose Patient fall rate Tracks the impact of interventions on actual fall incidents Staff adherence to protocols Measures compliance and engagement with new practices Staff and patient satisfaction surveys Assesses effectiveness of training and perceived safety Periodic audits Identifies areas for further improvement and validates sustained practice Organizational Culture Affecting Quality and Safety Outcomes Hospital culture, including shared values and hierarchical dynamics, strongly influences safety outcomes. Traditional hierarchical models can hinder open communication, causing staff to underreport falls due to fear of repercussions. A supportive organizational culture, emphasizing collaboration and safety, encourages reporting of near-misses and hazards, ultimately reducing fall incidents (Alabdullah & Karwowski, 2024). Positive safety culture enhances staff engagement, mitigates errors, and improves overall care quality. Conversely, prioritizing profit over safety reduces transparency, increases risk, and weakens fall prevention efforts. Justification of Necessary Changes in an Organization MUH must adopt a multi-faceted approach to reduce inpatient falls effectively: These interventions address current knowledge gaps, improve staff competency, and enhance patient care quality. Conclusion This analysis underscores the urgent need for systemic improvements at MUH to reduce inpatient falls. Patient falls result in physical harm, financial costs, and diminished care quality. Implementing evidence-based interventions, including staff training, environmental modifications, risk assessment protocols, and interdisciplinary collaboration, can significantly mitigate fall risks. These measures not only protect patients but also enhance institutional safety culture and quality of care. References Alabdullah, H., & Karwowski, W. (2024). Patient safety culture in hospital settings across continents: A systematic review. Applied Sciences, 14(18), 8496. https://doi.org/10.3390/app14188496 Albertini, A. C. D. S., & Peduzzi, M. (2024). Interprofessional approach to fall prevention in hospital care. Revista da Escola de Enfermagem da USP, 58, e20230239. https://doi.org/10.1590/1980-220x-reeusp-2023-0239en Ghosh, M., O’Connell, B., Yamoah, E. A., Kitchen, S., & Coventry, L. (2022). A retrospective cohort study of factors associated with severity of falls in hospital patients. Scientific Reports, 12(1), 12266. https://doi.org/10.1038/s41598-022-16403-z Leapfrog. (2024). Methodist University Hospital. Leapfrog Hospital Safety Grade. https://www.hospitalsafetygrade.org/table-details/methodist-university-hospital Saki, M., Ariaienezhad, B., Ebrahimzadeh, F., Almasian, M., & Heydari, H. (2023). The effect of nurses’ training on the implementation of preventive measures for falls in hospitalized elderly patients. International Archives of Health Sciences, 10(4), 144–149. https://doi.org/10.48307/iahsj.2023.183008 Strini, V., Schiavolin, R., & Prendin, A. (2021). Fall risk assessment scales: A systematic literature review. Nursing Reports, 11(2), 430–443. https://doi.org/10.3390/nursrep11020041 NURS FPX 6212 Assessment 1 Quality and Safety Gap Analysis Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2020). Fall prevention practices and implementation strategies: Examining consistency across hospital units. Journal of Patient Safety, 18(1), e236–e242. https://doi.org/10.1097/pts.0000000000000758 Usmani, S., Saboor, A., Haris, M., Khan, M. A., & Park, H. (2021). Latest research trends in fall detection and prevention using machine learning: A systematic review. Sensors, 21(15), 5134. https://doi.org/10.3390/s21155134