Date of Award


Degree Name

Master of Science


Occupational Therapy

First Advisor

Dr. Ben Atchison

Second Advisor

Dr. Diane Dirette

Third Advisor

Dr. David Orchanian

Access Setting

Masters Thesis-Open Access


Patient safety remains one of the most profoundly complex and important issues in healthcare systems especially regarding the use of restraint and the prevention of falls. Current topic guidelines suggest a "systems approach." These guidelines, however, oriented toward solution application using analytical problem-based approach. The development of this practice guideline was in response to a desire for theory-based practice that could guide outcomes. This practice guideline transforms systems theory into a guide for use by a leader/manager and a tool for the practitioner to rethink patient safety in a more holistic manner. This study was conducted in critical care, older adult behavioral, and long-term care settings to demonstrate the effectiveness of this practice guideline and its applicability, regardless of individual system attributes. Phase I - System Learning and Change, consisted of training the direct and indirect care staff; and Phase II - System Outcomes, consisted of output data to identify a special cause variation as a result of the training. Results indicate that direct and indirect care staff's knowledge, skills, and perceptions regarding their ability to make decisions improved. System outputs demonstrated a decline in restraint use in critical care and reduced fall occurrences in all three settings.