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

Debra Martinez

Second Advisor

Michael Bueno

Third Advisor

Danijela Pavlic


The purpose of this quality improvement project aimed at reducing falls on a medical-telemetry unit in a large metropolitan Magnet hospital. It was important for the MSN/CNL students to focus on falls because it is not just a concern for this institution, it is a national dilemma that needs to be addressed. Due to the complexities and intricate details of the IRB process, the MSN/CNL students were unable to collect data or further advance their project into the microsystem. Instead, information was attained from the University of San Francisco database to allow the MSN/CNL students to continue with the steps of the process.

The MSN/CNL students first focused on assessing the medical-telemetry unit by collecting data on the occurrences of falls. There were a reported 31 falls in the fiscal year 2016 with an increase to 36 falls in fiscal year 2017. Currently, patients are assessed for fall risk by using the Morse Fall Scale tool. The MSN/CNL students then split up into groups to observe nurses during shift report, during assessment of the patients for fall risk and while documenting the fall risk. After assessment, the Just-In-Time training was adapted and utilized. The Just-In-Time training focused on educating the nurses on the importance and proper way of implementing the Morse Fall Scale to decipher a patient’s fall risk. Success of the Just-In-Time training was seen when the nurse properly performed the Morse Fall Scale on their patients and felt comfortable using the tool. Once the phases of evaluation were completed, the MSN/CNL continued to evaluate to see if the number of falls decreased within the time frame given.