Date of Graduation

Summer 8-13-2021

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Problem: Falls as a leading cause of inpatient hospital injury show that intervention is needed to improve the safety and the health outcomes for this group of patients. Falls can not only significantly impact a patient’s physical being, but it can also affect them mentally, emotionally, and financially. In addition, inpatient falls leading to injury or complications can cause an economic burden on the hospital due to the increased associated costs such as the need for further diagnostic testing and treatment, a prolonged hospital stay, and from the penalty of Centers for Medicare and Medicaid Services’ (CMS) non-reimbursable events for hospital acquired conditions.

Context: Within the microsystem of a 32-bed telemetry unit at a San Francisco hospital, inpatient falls have continued to remain a challenge despite the use of standardized screening tools and universal fall prevention interventions.

Intervention: This project addresses the need for improvement and aims to decrease patient fall rates by 30% in a 12-month period. Enhancing staff engagement for the reduction of falls will be done by improving communication and processes, providing staff education, and optimizing the hospital’s physical environment.

Measure: Measures to evaluate effectiveness and to monitor the process will be done through the conduction of audits, nursing surveys for knowledge and satisfaction, and the analysis and trending of fall rates.

Results: Though there is insufficient data at this time to yield final results and compare to baseline and benchmarks, results are expected to generate a positive outcome with a trend signifying a gradual reduction of falls.

Conclusion: The proposed set of interventions are expected to promote staff awareness, involvement, accountability, and increase adherence to the implementation of fall prevention interventions. Furthermore, such efforts are expected to help improve the hospital’s safety culture which will lead to better patient outcomes, improve patient safety, satisfaction, and ultimately their quality of life.

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