Date of Graduation

Summer 8-6-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Cynthia Huff, DNP, RN, OCN, CRNI, CNL


Problem: Each year, thousands of patients sustain falls while hospitalized, resulting in an increase in serious injuries or death. In a Neuroscience Step Down Unit (NSDU), fall rates in 2022 were higher than the NDNQI benchmark. Despite a thorough fall prevention policy, nurses inconsistently implemented preventative interventions, resulting in increased falls.

Context: The NSDU is a 15-bed inpatient unit providing intermediate-level care for patients with neurological and neurosurgical diagnoses. The unit is part of a 459-bed academic medical center and safety net hospital providing tertiary and quaternary care in southern California.

Interventions: A bedside safety rounds checklist for charge nurses was implemented. The outgoing and incoming charge nurses completed the checklist during their bedside rounds at the 07:00 and 19:00 shift changes. Deficiencies were communicated to the assigned incoming nurse.

Measures: The outcome measure was the number of patient falls per month. Process measures included the percentage of patients with a fall risk assessment completed within two hours of admission and the percentage of bedside safety rounds checklists completed. The balancing measure was the percentage of patients not assessed for fall risk within two hours of admission.

Results: Between June 1 and July 31, 2023, patient falls decreased to two and zero, respectively. Of 191 patients admitted, 90% (n=172) were assessed for fall risk within two hours, the bedside safety rounds checklists were completed 89% (n=109) of the time, and 8% (n=15) of patients did not have a fall risk assessment completed within two hours of admission.

Conclusions: A bedside safety rounds checklist for charge nurses may have contributed to the decrease in the number of falls during the implementation period. In addition, staff were more engaged and focused on implementing the necessary interventions to minimize fall prevention.

Keywords: checklist, fall prevention, safety rounds, interventions, neuroscience, inpatient

Included in

Nursing Commons