Date of Graduation

Summer 8-21-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

MSN project

First Advisor

Mark Tungol

Abstract

Objective On a Telemetry unit at a level 1 trauma center public safety net hospital in the Bay Area, a review was conducted of 45 reported falls over the past year. The analysis uncovered inconsistencies in fall-risk assessment techniques, underuse of continuous observation among high-risk patients, and an absence of standardized purposeful rounding. These data points suggest existing tools were not being applied consistently, and need reinforcement and updating.

Aim This project aimed to reduce inpatient fall rates to the national benchmark by strengthening staff's consistent use of existing fall-prevention practices and infrastructure, including multifactorial risk assessment, purposeful rounding, and patient and family education.

Methods In June and July 2026, USF nursing students partnered with unit management and staff nurses to review the past year's fall data and develop a quality improvement intervention. A just-in-time education intervention addressing: multifactorial fall risk assessment, the 5 P’s of purposeful rounding, and patient and family education. A pre- and post quiz provided the immediate outcome measure for the intervention itself.

Results Mean quiz scores rose from 4.6 to 5.8 out of 6, and the proportion of nurses achieving a perfect score increased from 7% to 82%. The largest gain occurred on the item addressing the 5th P of purposeful rounding, “Pump,” where correct responses rose from 11% to 86%, indicating an ability to quickly absorb new content.

Conclusion The workforce is willing and able to learn quickly when given clear, well-targeted information. Framed through Rogers' Diffusion of Innovation theory, these results suggest the staff are ready to learn. Continued investment in qualitative assessments of the unit’s issues combined with targeted, low-burden education is likely to be productive.

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