Date of Graduation

Spring 5-19-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Tina Lemos


This paper explores falls, a sentinel event plaguing hospitals in the United States and internationally. Falls are a major contributor to negative patient outcomes and a source of financial strain for hospitals. One particular fall prevention intervention, Responder 5 bed alarms, was explored. A literature review on falls was conducted to study the effectiveness of bed alarms. Capezuti et al. (2009) found bed alarms to be error prone and stress the importance of patient risk factor assessment and using bed alarms as a multifactorial approach to fall prevention. Shorr et al. (2012) came to a similar conclusion after conducting a study on one unit of an urban hospital. The researchers increased the use of bed alarms but found that increased alarm usage did not result in reduced fall rates. University of San Francisco students undertook quality improvement work at a large metropolitan hospital suffering from high fall rates. Responder 5 bed alarm connectivity was studied to better understand factors contributing to falls. Forty nurses on one unit were interviewed and 83 fall risk patient’s beds were assessed. Ten out of the 83 beds (12%) assessed were connected to Responder 5. The data reveals lack of knowledge and underutilization of Responder 5. An intervention of an educational material was created. Once this intervention is implemented, future root cause analysis will be conducted to continue to understand and reduce fall rates at the hospital.

Included in

Nursing Commons