Date of Award


Degree Type


Degree Name

Doctor of Philosophy


School of Nursing and Midwifery

First Advisor

Dr. Nick Gibson

Second Advisor

Professor Di Twigg

Third Advisor

Professor Anne Williams

Field of Research Code

1110, 111004


Background: According to the Australian Bureau of Statistics (2013) falls and medication errors in hospitals are among the first twenty leading causes of death. Research on the relationship between nurse staffing, patient falls, and medication errors are limited. Even scarcer are studies that examine this relationship on a nursing shift by shift and ward by ward basis, and no research exists on shift overlap periods and adverse patient outcomes.

Objective: This study examined whether there was a relationship between hospital inpatient falls and medication errors and nurse staffing on a shift by shift and ward by ward basis, including an analysis of patient characteristics and the severity of incidents.

Research Design: Multinomial logistic regression models were used. Data were collected using a secondary analysis of two existing databases: Advanced Incident Management System (AIMS) database and the nursing staff roster database (RoSTAR) over two years (January 2011 to December 2012). The Kane framework of nurse staffing was used to guide the current study.

Setting: The study was conducted in three adult tertiary teaching hospitals in Perth, Western Australia.

Participants: Reports of 7,558 incidents that occurred during the study period from 76 nursing wards and wards (4,677 medical, 2,209 surgical, and 672 critical care wards incidents), and 320,009 nursing shift records in three hospitals, were examined.

Measures: The occurrence and severity of shift-level inpatient falls and medication errors were measured as dependent variables. Independent variables included nursing staff skill-mix, staff experience, and actual nursing hours. Control variables were shift, ward type, and hospital.

Results: This study supports the importance of RN staffing levels in improving patient outcomes. However, it also shows that the relationship between nurse staffing and patient outcomes can be affected by different factors such as patient characteristics, nurse characteristics, and ward type. The number of total clinical incident reports decreased by 7.4% from 2011 to 2012. Falls declined by 4.6% and medication errors declined by 10.8%. The average age of patients who fell or had medication errors was 56.3 years (range of 15 to 100 years) but was more common in patients over 65 years old (57.3%). The number of incidents was highest during the morning shift, less during the evening and lowest during the night shift (28.4%, 27.2%, and 21.8% respectively). Notably, 22.6% of total incidents were reported during the overlap period (13:00 pm to 15:29 pm) which is only two and a half hours. Medical wards had the highest incident records followed by surgical wards; fewer incidents occurred in critical care wards (61.9%, 29.2%, and 8.9% respectively). More registered nurses and more experienced staff on the shift were both associated with fewer falls and medication error incidents, as well as less severe injuries. An increase in the actual nursing hours was associated with fewer medication errors but not fewer fall incidents. However, an increase in in the actual nursing hours was associated with less severe falls but not less severe medication errors.

Conclusion: Overall, the fall and medication error incidents in three Perth hospitals decreased over the study period. However, the large variation in the incidents at both the shift and the ward level indicated room for improvement related to fall and medication error prevention. A relationship was identified between both more RNs and more experienced nurses in attendance and fewer incidents and less severe injuries. Further studies are necessary to identify prevention strategies for hospital falls and medication errors in the overlap period. Immediate consideration of the number of incidents that occurred during the overlap period is required. It is necessary to improve communication and teamwork among staff. Actions should be taken to review, implement and evaluate policies and procedures.


The Appendices are not included in this version of the theses


Paper Location