Date of Graduation

Summer 2023

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Susan Mortell

Second Advisor

Cunthia Huff


One of the most preventable reported safety incidents in hospitals is falls, resulting in adverse outcomes for patients, staff, and institutions. In the Observation /Telemetry unit (OTU) of a Bay Area hospital, falls are a growing problem. Hospital-wide, the unit has experienced the most significant number of falls from January 2022 to January 2023 with resulting injuries. Despite fall prevention efforts, the implementation of standard fall prevention measures has been inconsistent due to high staff turnover and many new inexperienced nurses. Therefore, it is essential to implement a quality improvement program to improve the health and safety of patients. The CNL developed a fall prevention project incorporating the Fall Tips developed by AHRQ (Agency for Healthcare Research and Quality) to decrease the number of falls per 1000 bed days and reduce the monthly falls rate by 25%. The project using Fall Tips reduced the monthly fall rate from 3 falls in April to one in May, a decrease of 66.66%. While the project implementation was successful, there is too little data to establish a trend. There was a decrease in falls per 1000 bed days from a baseline in the Q4 of the fiscal year of 3.50 to 2.76 in Q2, an improvement of 21%. While the results showed a successful quality improvement project, it is difficult to conclude that the significantly improved result was due to the program or other factors. Long-term success will depend on staff awareness, continued commitment to reducing falls, fidelity to the fall prevention processes, and leadership that supports staff through blame-free culture and adequate staffing.

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