Date of Graduation

Fall 12-16-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


The Effects Orthostatic Hypotension has on Falls: A Study Done in San Francisco Represented

Population of the Veterans Affairs Hoapital

The global AIM of this project is to Identify patients that are at risk for Orthostatic Hypotension (OH) with in the first 24 hours of addmission. It was identified that 50% of the falls over the last 4 quarters at the VA were OH related. The patients were not identified as a fall risk and over half of them had fallen multiple times. After performing a nursing survey online, a SWOT analysis, and a Root Cause Analysis using a fishbone diagram, The problem was identified as a gap in knowledge for the assessment of OH and poor implementation and standardization of the current fall program. The 124 bed unit of 2 B South is a Telemetry/Seizure unit that has over-flow from TCU. The patients are all Veteran’s, many who suffer from multiple co-morbidities, including psychiatric conditions and Post Traumatic Stress Disorder (PTSD). As the Clinical Nurse Leader (CNL) I will build and strengthen this project using two essential competencies. The first #3 Quality Improvement and Safety as this is the AIM of the project, to reduce falls. The second is #7 Interprofessional Collaboration for Improving Patient and Population Health Outcomes, through working with the medical staff on the unit we will build a strong team to enhance the quality and satisfaction of the patient. Evaluation of the OH patient at risk for falls, as defined by the Merck Manual, will be assessed following the guidelines of the Morse Fall Scale (MFS). 3 cycles of PDSA were ran over a weeks time to gain more specific information of gaps in knowledge and program process. I used Lewin’s Change Theory and Kotter’s Eight-Step Process for Leading Change. I selected two theories to guide me due to the staffs resistence to change, this has been a strong barrier dueing my rotation. The nursing surveys were done through an online questionaire to allow privacy and honest answers, I often made rounds on the unit meeting independantly with staff as well as visual assessments. Through the use of Evidence-based data, the current falls program was updated to incorporate OH patients. I have designed a patient pamphlet to help the nurses teach patients about OH and how it relates to falls. The project met or exceded the goal of reducing falls by 35% and repeat falls by 50%. The project started working with pharmacy and IT to change the charting process and identify patients that are on medications that could cause OH. These changes will not be in effect due to the projects length of 3.5 months, but the CNL preceptor will continue the project with the appointed Fall Champions. Education to the nurses was delivered by a projection power point on the wall once a month for 15 minutes. As the knowledge grew, the nurse became more confident and change started to take place. By mid November the staff, at 87%, had almost reach the 24 hour OH assessment goal of 95%. We celebrated small wins as a team with bagels or special treats. The nurse manager was able to get one paid day off for each of the Champion, with the restriction that each month they be reassessed for participation. My biggest surprise implementing this project was that this unit had just started hourly rounding and they were not doing post fall huddles. We did start PFH with this project as it is the best way to dissimenate information. It is proven research PFH reduce fall rates. Pre fall project the fall rate in July was 7 with 4 reoccuring falls at the end of the project the October fall rate was 2 with no reoccuring falls.