Date of Graduation

Fall 12-17-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone



Problem: Falls are considered never events, yet continuously occur in the inpatient setting. Falls,

especially falls with injuries, impact the patients, the staff, and the hospital. Falls cause extended lengths of stay, affect the morale of the patients and the staff, and are non-reimbursable events.

Context: There have been an increased rate of falls within a medical/surgical/telemetry unit

microsystem at a Northern California hospital despite standardized screening and prevention tools. The unit can house up to 52 patients and is the designated Covid unit of the hospital at the time of this project.

Interventions: The interventions include optimizing the patient’s environment using interconnected bed alarm and call light technology, as well as engaging staff and patients using an informational fall prevention care board for identified high fall risk patients.

Measures: Evaluation measures will include visual room inspections and electronic medical

record audits while tracking the overall inpatient fall rate within the microsystem over the period of the project.

Results: A positive outcome through the implementation of the proposed interventions was

achieved as shown by the overall decreased average inpatient fall rate within the unit.

Conclusions: The proposed interventions were intended to ease real-time bed alarm discovery

and engage and involve staff in the creation and implementation of fall prevention ideas; this was to promote accountability within the staff themselves as well as encourage innovative solutions to unit problems going forward. The inclusion of bedside staff throughout the development and implementation of the project ensured continued adherence and prompted continual project revision towards success.

Keywords: safety, fall prevention, injury, hospital, California, alarm, care board