Today, the Joint Commission requires that all healthcare facilities have a falls prevention program. Facilities are also required to conduct ongoing program evaluation (Hubbartt, Davis, & Kautz, 2013). Most prevention programs include the use of a bed alarm, but can bed alarms alone prevent falls? This article will look at using a bed alarm as the sole tool to prevent falls. It is often found that even when a bed alarm is triggered, the patient has already fallen before the nursing staff can enter the room. This article will also examine the use of other prevention measures that can be used independently or in conjunction with bed alarms to help reduce the number of falls and the related theory of change that would work best to implement this change in the practice. Nurses are leaders and should always strive to identify and resolve seemingly obvious issues with the best interests of the patient, family, and nursing staff in mind. First, identify the factors that contribute to a patient's fall. Many patients who appear to be at high risk of falling and who may use a bed alarm are patients with cognitive impairment, who have an unsteady gait, patients who have many wires or lines and who need assistance of a nurse or a patient. caregiver (APC) to move and patients who pose a threat of violence. Other factors that contribute to falls include the bed or chair exit alarm not being activated, the alarm not being set up correctly, family members turning off the bed alarm or attempting to helping the patient get out of bed, alarm malfunction or infrequent checks on the patient to make sure they are comfortable middle of paper...... lead to results more important. Finally, the eighth step is to make the change stick, although now each team member should demonstrate the new interventions the nursing team should work on to ensure this continues throughout the the practice. Offering rewards for achievements such as no falls per month will help ensure everyone continues to work towards this goal. In conclusion, it is clear that patient falls can cause a multitude of problems and for many hospitals and healthcare facilities, falls appear to be a problem. Working to reduce these falls with more than one intervention has been shown to be beneficial. Preventing the number of falls in a hospital will not only prevent injuries that occur when a patient falls, but will also help reduce the number of times a patient is readmitted to the hospital and delay their recovery..