Fall 2022

Document Type

Scholarly Project


College of Nursing

First Advisor

Dwayne Alleyne


Problem Statement: The Emergency Department (ED) is a fast-paced environment where the risk of communication failure enhances due to the variation in patient acuity, variety of shift options, and constant interruptions (White- Trevino & Dearmon, 2018). Ineffective communication can lead to increased adverse events, medical errors, and poorer patient health outcomes (Campbell & Dontje, 2019). Additionally, medical errors, such as falls, are more likely to occur during handoff when nurses change shifts (Campbell & Dontje, 2019). The most reoccurring medical error in the ED is patient falls.

Purpose: This quality improvement project aims to introduce a structured handoff rounding

tool, I-PASS, within a level one trauma ED in the southeastern United States. Improving communication and heightening situational awareness of fall precautions during bedside reports may reduce patient falls, thus increasing patient safety.

Methods: The I-PASS communication handoff tool was implemented amongst nurses within an adult ED for three months. Participants' adherence to I-PASS and the number of patient falls were measured after educational sessions.

Inclusion Criteria: Registered nurses in the adult ED

Exclusion Criteria: Travel nurses, float nurses, temporary nurses

Analysis: The result of the two-tailed paired samples t-test was not significant based on an alpha value of .05, t (2) = -0.09, p = .933. Findings suggest the difference in the mean of pre-intervention total falls in 2021 and the mean of post-intervention total falls in 2022 was not significantly different from zero.

Implications for practice: Implementing a handoff communication tool at the bedside amongst nurses during shift change will improve communication and assist in identifying those at higher risk for falls. As a result, it may lead to a decrease in falls.

Included in

Nursing Commons