Date of Graduation

Winter 12-15-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Mary Seed


National organizations such as the Centers for Disease Control and Prevention (CDC) and the Collaborative Alliance for Nursing Outcomes (CALNOC) have prioritized reduction of inpatient falls as a patient safety goal. An improvement project utilizing the model for improvement and Plan-Do-Study-Act (PDSA) cycles was conducted on a 40-bed unit that provides care to cardiac, and medical-surgical patients. The current fall prevention quality council team is composed of nurses and interdisciplinary clinicians, who focus on improving clinical and financial outcomes related to fall prevention and potential injuries. A Clinical Nurse Leader (CNL) was asked to lead a practice improvement project in response to chart audits and observational rounding that indicated a gap in patient awareness of fall prevention activities and lack of consistent implementation of established fall prevention measures by nursing staff. The aim of this project was to increase awareness and knowledge of patients related to fall prevention and staff education to improve reliability of implementation actions to reduce falls. Data was collected over a three-month period and new interventions including a fall prevention tool kit and communication campaign – “Call Before You Fall” were developed and implemented to reduce fall rates by 50% every month. Results from staff education are expected to improve based on pre and post data comparison of education provided during shift huddles. Data results post intervention proved to decrease the rate of falls. Clearly, fall prevention activities need to address both communication and education interventions to improve fall reduction outcomes.