Date of Graduation

Summer 8-9-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Dr. Sarah Horton-Deutsch

Second Advisor

Dr. Cathy Coleman



One million hospitalized people fall annually in the United States, and up to a third are preventable.


Data from an acute care hospital show one medical-surgical unit reported eight patient falls in 2021, two causing major harm that reached sentinel event criteria.


A Clinical Nurse Leader (CNL) leveraged the unique CNL skill set and characteristics of Human-Centered Leadership to engage in horizontal leadership, injury prevention, and team coordination through authentic human connection. The team leveraged documentation for improved fall risk communication. Unavoidable disruptions hindered other planned interventions.


Outcome measures observe for total fall count and the rate of falls with injury. Three balancing measures monitor for patient mobility, physical restraints, and employee injuries during the effort to reduce patient falls.


Since January 2022 (i.e., six months), the unit has had zero injury falls and achieved eighty-nine consecutive days without a patient fall. The total fall count is constant at both the unit and hospital levels; however, there is a shift in fall severity. There have been no moderate-harm, major-harm, or sentinel event patient falls since the onset of this quality improvement process. The balancing measures are all favorable.


Increased awareness and focus on fall prevention positively affected safety culture and reduced patient harm. Outcomes endorse leveraging the expertise of the CNL and Human-Centered Leader, inviting participation in change by engaged teams, and a little luck to avoid disruptions at critical times in the project lifespan. Applied interventions are generalizable to other interprofessional teams.