Date of Graduation

Summer 8-8-2023

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

Dave Ainsworth

Second Advisor

Liesel Buchner

Third Advisor

Sara Horton-Duestch



Problem: Every year, there are many in-hospital falls (IHFs). Nationally there are between 700,000 to 1 million falls recorded each year. Hospital falls financially burden our healthcare industry, costing approximately 34 billion annually. Context: In a local hospital in Northern California, Marin County, the microsystem has had an extraordinary number of in-hospital falls (IHFs). To date (June 2023), 13 falls have been recorded thus far; the microsystem is on track to beat the previous year's record number of 21 falls in a calendar year. Interventions: The MSN–CNL student proposed re-educating staff, resetting expectations, and reestablishing workflow. We also sought to include leadership in rounding. Moreover, a focus on patient education was pivotal to the quality improvement project's (QIP) success. Outcome Measures: The MSN-CNL student established a goal of a 50% reduction in IHFs by the end of the calendar year for 2023, from 21 falls to 10.5 falls; this translates to 0.875 falls/month. The MSN-CNL student projected a measure of 4.38 falls within the Master's program target time of 5 months (January to end of May). A reduction in falls would result in several positive outcomes; for the microsystem, a net saving in cost-avoidance; increased morale for nursing staff; and regain the lost trust of the patients, family, and community regarding overall safety. However, during the Master's program period, ten falls had already occurred by the end of April. The MSN-CNL student had to reset goals. A new goal of a 20% reduction in falls or 16.8 falls for 2023 was established (1.4 falls/month). Results: To date, there have been 13 recorded IHFs in 5 months (Jan.-May); this equates to an average of 2.6 falls/month during the development of the QIP. As a result, we did not meet our initial target or our new goal of 7 falls (1.4 falls/month) in the five months (Jan-May). After QIP implementation, at the beginning of June, we recorded a slight but measurable decrease in the average of IHFs from 2.6 falls/month to 2.0 falls by the end of June. Conclusion: After reestablishing expectations, completing the re-education of nursing staff, establishing leadership rounds, and including education of patients and their families in workflow, there has been a measurable reduction in the number of in-hospital falls.