Date of Graduation

Spring 5-17-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Elena Capella


The CNL project was conducted on the 56-bed adult medical-surgical units in a trauma center. There were total eight fall incidences from January to February. The SWOT analysis, stakeholder analysis, pre-educational survey, cost-effective analysis and root-cause analysis suggested in-depth training on multifaceted fall prevention. The objectives include reducing falls by 50%, increasing staff’s adherence to fall prevention protocols, boosting staff’s confidence in patient mobility, improving staff responsiveness and communication with meds in HCAHPS, and enhancing knowledge of medications’ side effects by May 14, 2018. The literature reviews indicated that the multicomponent preventative measures to prevent falls along with leadership supports might effectively reduce falls (France et al., 2017). The project incorporated Lewin’s change theory and followed the model of Plan-Do-Study-Act (PDSA) to test, refine, and sustain changes (IHI, 2016; Wojciechowski et al., 2016). The project strictly followed the timeline. In April, the unit achieved 80% of fall reduction. Staff responsiveness and communication with meds in the HCAHPS survey are 3.2% and 20% above the target goals. The fall bundle compliance rate reached 100%. The post-surveys showed 100% of understandings of side effects of specific medications and 81% of staff’s confidence in patient mobility. 85% of staff expressed improved hand-off communication about the patient’s mobility status. Education on multicomponent fall prevention strategies, shared fall data on fall dashboard, installation of Stryker bed cords, leadership rounding, and multidisciplinary collaborations, showed positive outcomes on fall reductions. Sustaining results and confronting barriers will require actions from leaders and front-line staff in the future.