Date of Graduation

Summer 8-13-2026

Document Access

Restricted Project/Capstone - USF access only

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 Falls are one of the most common and costly safety events in acute care hospitals. A single inpatient fall costs a hospital an average of over $62,000. The medical-surgical telemetry unit for this project had a fall rate of 5.32 falls per 1,000 patient days, higher than the national benchmark of 3.5-3.6. A microsystem assessment found inconsistent fall risk assessment, documentation, and purposeful rounding on the unit. Aim This project aimed to reduce patient falls on the medical-surgical telemetry unit to the national benchmark of 3.5-3.6 falls per 1,000 patient days within 6 months. This was to be done through a Just-in-Time (JIT) fall prevention education for RNs. Methods The JIT education was guided by Lippitt's Seven-Step Change Theory and tested using the Plan-Do-Study-Act (PDSA) cycle. It covered multifactorial fall risk assessment, an expanded 5 P's approach to purposeful rounding, and patient and family education. It was delivered one-on-one to 29 RNs across two sessions. Each RN completed a 6-question quiz before and after the education. Results Average quiz scores went from 4.7 out of 6 (78.3%) to 5.57 out of 6 (92.8%), a 14.5 percentage point increase. Before the education, only about 11% of nurses correctly identified the newly added 5th P, compared to 86% after. Most nurses rated the education positively, with 44.8% saying it was extremely helpful and 41.4% saying it was very helpful. Conclusion RN knowledge of fall prevention practices improved after the JIT education. The intervention was delivered over a much shorter window than the project's full evaluation period. Because of this, it was not possible to determine whether this knowledge led to fewer falls. Continued monitoring by unit leadership will be needed to see the intervention's long-term impact.

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