Reducing Patient Falls Through Just-In-Time Education Fall Prevention Education on a Medical-Surgical/Telemetry Unit

Author

• Zaira Garcia VegaFollow

Date of Graduation

Summer 8-13-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

First Advisor

Mark Tungol

Abstract

Objective: To implement the Just-In-Time (JIT) fall prevention education on a telemetry unit as a small-scale pilot to determine whether it improved nurses’ knowledge of evidence-based fall prevention practices, including the 5 Ps of purposeful rounding, multifactorial fall risk assessments, and patient and family education. Aim: This project aims to reduce patient falls on the telemetry unit to the national benchmark within 6 months through implementation of a JIT prevention education program for RNs. Methods: A brief JIT education session focusing on the 5 Ps of purposeful rounding, multifactorial fall risk assessment, and patient and family education was delivered to a total of 29 RNs across day and night shift. RNs completed a six question pre-quiz before the education and a post-quiz containing the same six questions, two additional demographic questions, and one satisfaction question following education. Pre- and post- quiz scores were compared to assess changes in knowledge and effectiveness of JIT education. Results: The pre-quiz score was 4.7 out of 6 (78.3%), which increased to 5.57 out of 6 (92.8%) on the post-quiz, showing a 14.5 percentage point improvement. Before the intervention, 24 RNs (83%) were unable to identify the fifth P, “Pump,” which was not a part of the unit’s existing purposeful rounding practices. Most RNs rated the education as very helpful (41.4%) or extremely helpful (44.8%). The project's outcome measure, inpatient fall rate, could not be evaluated because of the 10-week project timeframe. Conclusions: Findings suggest that a brief JIT education session may improve RN knowledge of evidence-based fall prevention practices. However, due to the project’s time constraints, it cannot be determined whether improved knowledge translated into a reduction of falls on the unit. Long-term implementation and continued monitoring of fall rates and fall prevention practices are needed to evaluate the intervention’s impact.

Recommended Citation

Garcia Vega, Zaira, "Reducing Patient Falls Through Just-In-Time Education Fall Prevention Education on a Medical-Surgical/Telemetry Unit" (2026). Master's Projects and Capstones. 2079.
https://repository.usfca.edu/capstone/2079