Date of Graduation

Fall 12-15-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


This project focuses on the prevention of patient falls in the emergency department (ED). Kaiser Santa Clara Hospital is an academic medical facility in the heart of Silicon Valley. The facility has a 46 bed ED with an average daily census of 220, specializing in stroke, pediatrics, heart, and left-ventricular assist device (LVAD) patients. For the calendar year of 2016 there were thirty-reported patient falls in the ED. The global aim is to reduce the patient fall rate by 35% for the 2017 calendar year. The project’s objective is to continue the road to patient safety and to have less than five falls occur from September 1st to December 15, 2017.

An identified gap revealed there was room for hands on involvement by the ED leadership team. The CNL competencies of team manager, data analyst and advocacy were capitalized. Through collaboration with the ED Fall Committee and ED Assistant Nurse Managers (ANM) daily intentional nurse leader rounds on fall risks were introduced. At the start of September the ANM team began performing three intentional nurse leader rounds on identified falls risks. Intentional nurse leader rounds are similar to purposeful hourly rounding but with a greater focus on ensuring fall prevention interventions were utilized on behalf of the bedside nurse.

The global aim of reducing the total ED patient falls by less than 35% for 2017 will be achieved. The addition of intentional nurse leader rounds on identified fall risks will help provide direct interventions and real-time feedback to preserve a culture of patient safety in the ED. In fact, leadership involvement will foster shared ownership in quality improvement.