Date of Graduation
Summer 8-6-2025
Document Access
Project/Capstone - Global access
Degree Name
Master of Science in Nursing (MSN)
College/School
School of Nursing and Health Professions
Program
Kaiser cohort MSN capstone
First Advisor
Sarah Horton Deutsch
Second Advisor
Catherine Coleman
Abstract
Abstract
Problem: Globally, hospital falls remain a leading cause of injuries, increased costs, short and long-term disability and emotional impact on patients/families. Despite required prevention measures, a local hospital experienced rising fall rates during 2024 (n=71);13 of these occurred in the Med-telemetry microsystem. Although multiple strategies and financial investments occurred, nursing compliance with the fall prevention “bundle” remained suboptimal.
Context: Thirteen falls resulted in $182,000 in 2024. A quality improvement (QI) project was initiated over 12 weeks after routine audits revealed inconsistency in application of several components of the required bundle: particularly, the fall prevention video upon admission.
Interventions: A standardized four-minute video highlighted key safety interventions to reduce risk. A clinical nurse leader (CNL) or designate audited compliance and patient understanding of the video using a 3-question survey conducted every shift during rounds.
Outcome Measures: To increase patient video education upon admission to 80% from 0 % baseline. Two process measures included training 90% of staff (n=38) and surveying patients (n=311) to determine improved verbal understanding of safety measures after video education.
Results: Staff adherence to the patient education video increased from 0% to 89%; 5% of patients stated the video was not introduced; and 6% did not remember. The weekly “harm report” indicated that two falls occurred compared to six during a similar timeframe in 2024.
Conclusions: Standardized fall bundles require consistent reinforcement to optimize patient and organizational outcomes. This project increased nursing compliance and decreased falls by targeting patient/family education and enhancing team communication.
Recommended Citation
Zere, Fithawit T., "Enhancing Patient Safety: Fall Prevention through Video Education" (2025). Master's Projects and Capstones. 1905.
https://repository.usfca.edu/capstone/1905
