Date of Graduation

Winter 12-16-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Carlee Balzaretti

Second Advisor

Dr. Elena Capella


Patient safety is one of the major concern of any healthcare provider during their patient’s hospital stay. This project addressed the steady trend of fall incidences compared to last fiscal years’ data of an average of 4 falls per month. This trend created urgency to envisioned a plan for solutions to prevent this circumstance from happening. This Clinical Nurse Leader led a project in creating a process in identifying all patients that are high risk to fall (HRTF) prior to their admittance or transfer to Medical Surgical/Intermediate Care Unit and throughout their hospital stay until they are discharged. In addition, a fall prevention action plan was generated for all staff members to follow to ensure the safety of our patients. Kotter’s Eight-Step Process for leading change was utilized for this project. Several literature reviews revealed that incorporating patient-centered hourly rounding, discussion of HRTF patient during huddle time along with utilization of fall prevention methods were evident practices that should be implemented by all staff members to decrease falls within the microsystem. Since the implementation of fall prevention action plans, the microsystem remained on track in achieving its goal by decreasing fall episodes by 25% by the end of the 1st quarter (September 2016) compared from the previous quarters (July 2015 to June 2016). Fall Prevention Survey was conducted to evaluate the understanding and how the staff members were engaged in preventing falls. Eighty-five percent of staff members participated in the survey which had a positive perspective of the process in preventing falls. Through multiple cycles of PDSA, changes will be implemented accordingly in decreasing falls in the unit which led to improving patient care and efficiency and ultimately improved patient outcomes.

Nursing 653_Module 11_Poster Presentation.pptx (6011 kB)
Final Presentation