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 paper will summarize the quality improvement falls prevention project conducted by a group of University of San Francisco Clinical Nurse Leader (CNL) students. Falls in the acute care setting are a major issue in the current health care system and are a main topic of interest for CNL students to address in order to demonstrate their competency in risk reduction, health promotion, and evidence-based practice. A large, metropolitan hospital uses the Morse Fall Scale to assess patients for fall risk factors. On a medical-telemetry floor, fall incidence rates are increasing from the previous fiscal year. Due to the negative impact of falls on patient outcomes, the CNL students conducted a systematic analysis of the problem. The results were used to design, implement, and evaluate an evidence-based practice intervention to address the root cause of falls on the unit. The systems theories used in this quality improvement project are Chaos Theory and Kotter’s Eight Step Change Model.