Date of Graduation

Summer 8-4-2026

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

Dr. Cathy Coleman

Second Advisor

Dr. Sara Horton-Deutsch

Abstract

Problem: Inpatient falls remain a significant patient safety concern associated with preventable patient harm, prolonged hospitalization, and increased healthcare costs. Routine fall bundle validations identified inconsistent adherence to safe bed configuration practices, such as beds left raised and bed alarms turned off.

Context: A 3-month quality improvement project was implemented on a 20-bed medical-surgical telemetry unit within an integrated healthcare delivery system at a 130-bed community hospital in Northern California, which was experiencing an increase in inpatient falls and fall-related sentinel events.

Interventions: Implementation of bed-monitoring technology with visual indicator lights that provided real-time feedback on bed configuration.

Measures: The process measures included daily audits of safe bed configuration by nursing leaders every shift. Outcome measures calculated inpatient fall rates before, during, and after implementation.

Results: Baseline safe bed configuration compliance was 92% and increased to 97% following implementation and exceeded the project goal of 95%. Pre-implementation fall rates averaged 0.83 falls per month compared with 0.33 falls per month during the six months following implementation, representing a 60% reduction in falls.

Conclusions: Implications for nurse leaders extend beyond a single microsystem; successful fall prevention depends not only on the introduction of new technology but also on leadership support, consistent staff education, and ongoing reinforcement of best practices. Integrating bed-monitoring technology, staff education, and interdisciplinary collaboration fostered a culture of continuous learning and safety, resulting in reduced inpatient falls.

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