Date of Graduation

Summer 8-21-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Mark Tungol

Abstract

Objective: Patient falls remain a leading cause of preventable harm among hospitalized adults and carry significant clinical and financial consequences. On an adult medical-surgical telemetry unit at this study site, a one-year review of 45 fall events found that most falls occurred among patients classified as high risk on the Morse Fall Scale, frequently without continuous observation or consistent purposeful rounding. Aim: The aim of this project is to reduce falls on the telemetry unit to the national benchmark of 3.2 falls per 1,000 patient days within a 6-month period. Methods: A just-in-time (JIT) education intervention was delivered to registered nurses, targeting the 5 Ps of purposeful rounding, medications and comorbidities that increase fall risk, and patient and family education to reduce unassisted high-risk activity. Staff knowledge was measured with a pre and post knowledge quiz, and fall events were tracked through the MIDAS reporting system. Results: On the telemetry unit, 29 bedside RNs on both day and night shift completed a pre- and post-quiz that evaluated the effectiveness of the JIT intervention. Mean scores increased from 4.66/6 (77.6%) to 5.69/6 (94.8%), a 22.2% relative increase, with 79.3% of RNs improving their score. Due to timeframe constraints, fall rate data for the 6 months following implementation was not able to be found, but is a recommended outcome measurement for future PDSA cycles. Conclusions: Immediate improvement in RN knowledge of fall prevention practices were measured after a brief, low cost, JIT education intervention. Sustaining this improvement with the goal of a reduction in patient falls will require further implementation and development of the project to embed it into unit culture rather than rely on a one-time training.

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