Date of Graduation

Spring 5-19-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


One of the most important aspects of patient safety is the prevention of patient falls (PFs). PFs are a never event and are preventable. The project addresses the ongoing increase in PFs on a medical-surgical oncology unit in an inpatient hospital setting. The increase in PFs created urgency to provide solutions to these preventable circumstances. This Clinical Nurse Leader (CNL) led the project and conducted a comprehensive microsystem assessment of the potential causes of PFs calling for further investigation of the unit’s current fall policy. After conducting two surveys of both the nursing staff (NS) and patients’ knowledge of fall interventions preventions (FPIs), it was known that only 40% of the NS had knowledge of the unit’s policy T.E.A.M. (Toileting, Environment, Activity, and Medication) bundle FPIs. Moreover, only 20% of patients surveyed knew they were at high risk for falls. Utilizing Kotter’s Eight-Step Process for Leading Change, the CNL performed a literature review revealing that to prevent PFs, evidence-based practices must be implemented and known by both the NS and patients. Visual aids, a flyer for NS and pamphlet for patients, were created to educate the NS during huddles on T.E.A.M. interventions and to educate their patients on admission regarding FPIs. By huddle four, 80% of the NS increased their knowledge of T.E.A.M. FPIs and again 20% of fall-risk patients knew the FPIs. Currently the educational pamphlet for patients is awaiting approval. Although there was no increase in measuring patient’s knowledge of these FPIs, the staff continues to be aware that they are required to educate patients on admission about FPIs. Eighty-percent of the staff state that a pamphlet would help them educate patients on FPIs. This will continue this CNL’s work through the next PDSA cycle aiming to increase patient knowledge on FPIs.

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