Date of Graduation

Fall 12-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Dr. Cynthia Huff


Problem: Maintaining patient safety is of utmost importance in healthcare. Healthcare organizations develop policies and protocols to minimize preventable harm and deliver care safely. However, hospital falls continue to occur, and preventing falls remains challenging. Falls and fall-related injuries can significantly impact the patient’s quality of life, cause prolonged hospital stays, and higher hospital expenses. Implementing an effective fall prevention program is imperative.

Context: There has been an increased incidence of falls within two medical-surgical units (5C and 5D) at Hospital J in Northern California despite using fall prevention measures such as hourly rounding, wearing yellow skid socks and yellow armbands, bed or chair alarms, and fall prevention signages. The units have 56 beds for oncology patients and patients with acute and chronic cardiac, pulmonary, gastrointestinal, urological, and gynecological diseases, as well as those requiring post-operative care.

Interventions: The interventions include using the Fall Tailoring Interventions for Patient Safety (TIPS) tool posted in the patient’s room. The assigned nurse will engage and educate the eligible patient and family members about the use and benefits of the tool in fall prevention. The goal is to reduce the incidence of falls in the two medical-surgical units by 50% after six months of implementation.

Measures: Monthly auditing of the number of falls in each unit, hospital staff compliance with the Fall TIPS tool through room surveys, and the number of restraints and sitters used through the electronic record will be evaluated. The hospital’s falls committee will monitor these data after six months and assess for any revision needed quarterly.

Results: The results indicate a downward fall trend within the two units. Initially, both units had 15 falls from January 2022 until June 2022. After six months of implementation, there was a total of 10 falls. Although it did not successfully reach the target goal of 50%, the data shows a 40% reduction in falls. In addition, there was increased engagement from the hospital staff and patients in fall prevention.

Conclusion: This project had a positive outcome as it reduced the number of falls in the two medical-surgical units. The hospital staff and the falls committee must continue working together to ensure the fall prevention tool's continued adherence and sustainability. Engaging every stakeholder in this objective can improve patient safety, outcomes, and satisfaction.