Date of Graduation

Winter 12-20-2019

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


Implementing a fall prevention program is imperative in acute healthcare settings. Falls are one of the top reported events that occur in hospitals and it is a patient safety concern that requires the implementation of evidence-based practices to reduce falls. This quality improvement project will be developed by a master’s prepared clinical nurse leader (CNL) on a medical-surgical unit to improve patient safety.


Maintaining patient safety is the most important priority in health care. Health care organizations implement protocols, policies and procedures to ensure that care is provided in a safe manner to minimize preventable harms. However, falls are unexpected incidences that occur in health care settings but are considered to be preventable occurrences. Falls can lead to serious injuries and even death; these events are known as sentinel events (The Joint Commission [TJC], 2013).

According to the TJC (2016) inpatient falls are one of the top reported sentinel events occurring in hospitals and are considered a serious problem because it compromises patient safety. According to Walsh et al. (2018) and Zhao et al. (2019) in the U.S. the average fall rate of adults in a medical and surgical (M/S) unit is 3-5 falls per 1,000 patient days, in which 26.1% result in serious injuries including death. The existing problem in a Medical-Surgical (M/S) unit is that there was a 44% increase in falls this year in comparison to the previous year. Therefore, implementing a fall prevention program focusing on patient mobility is imperative.


The M/S is an inpatient unit that has three floors with a total of 110 beds that serves a diverse population of patients. The M/S unit provides medical services adult patients. The unit provides treatment for acute and chronic medical conditions such as cardiovascular, pulmonary, and renal diseases as well as others. The M/S unit has been diligently working on focusing on purposeful hourly rounding as a method to decrease in patient falls but it has not yielded the desirable outcome of a reduction in falls.


The proposed plan is to implement a fall prevention program that is centered around promoting patient mobility on the M/S unit to decrease patient falls. The CNL will establish a multidisciplinary team known as the mobility/fall task force to collaborate on developing a standardized mobility program that can be modified to meet the needs of each patient. This program will be multifaceted as it will also include performing a fall and mobility assessment and the use of several mobility tools in place along with the development of a patient mobility goal plan tool that will be incorporated into this fall prevention program. The goal is to reduce the incidence of inpatient falls occurring in the M/S unit by 25% by the end of December 2019 and 50% by December 2020. This program is currently underway.


To determine the success of this project, several data sets will be collected by auditing nursing documentation of the following: nursing fall risk and functional mobility assessments, patient daily mobility activities, and hourly rounding. Additional data will be collected through the review of incident fall reports as well as the review of monthly length of stay. These measurements will be analyzed first on a weekly basis for two weeks, followed by a bi-weekly basis for four weeks, then monthly for six months, and every three months thereafter. The data collected will then be entered in a Microsoft Excel spreadsheet to graph the information to depict the changes occurring over time. The graphs will reflect if there are any changes indicating positive outcomes through the introduction of this fall prevention program.


The fall prevention program was initiated in August 5, 2019 and trialed for two weeks on all three floors in the M/S unit. The program officially began on August 19, 2019. The outcomes measured included fall rates, percent of patient being ambulated and length of stay. At this point, there is insufficient data available to determine the trend of the success, but the initial results indicate positive outcomes since the program was implemented. Although it is not the target goal of 25% reduction, data indicates that there has been a 7% reduction in falls. Further, data shows that there also was a decrease in length of stay (LOS). However, the percent of patients being ambulated was below the desired target goal.


The preliminary results indicate that having the CNL implement and lead the fall prevention program has shown positive outcomes in the reduction of falls occurring in the M/S unit per month. To continue the success of the program, the CNL will continue working closely with staff to assign a unit champion by floor per shift to ensure sustainability. The mobility/fall task force will continue meeting regularly to monitor success of the program and discuss ways to continue preventing falls. The success of this program will indicate that having a CNL collaborate with a team to implement quality improvement projects can lead to improved patient safety and better patient outcomes.