Date of Graduation

Spring 8-7-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


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First Advisor

Dr. Ellena Capella

Second Advisor

Dr. Nancy Taquino



The purpose of the project was to decrease the number of falls occurring in the 48-bed medical-surgical unit by building standard work for hourly rounding and communication. Falls are a patient safety issue and are preventable. Since the Institute of Medicine has published “To Err is Human” in 1999, there have been a multitude of studies on falls, yet falls continue to be prevalent in health care organizations. The increase in patient falls adversely impact the patient’s length of stay, discharges to nursing homes and the facility’s reputation for providing safe care. The staff in this microsystem used the Schmid falls risk assessment and several other universal falls prevention practices. To decrease the patient falls and increase patient safety, these current practices were evaluated, to determine the most effective evidence-based practices. The unit achieved a 30% reduction in falls in six months after simulation training on the correct processes for hourly rounding. Concurrently the staff utilize the patient care board for communication between workers on the type of assistance and device the patient will need to get out of bed safely for toileting needs. Development of a method for training and educating new staff on the practice of standard work for hourly rounding and communication on patient’s toileting is needed for continuous improvement.

Keywords: falls, hospitalized, prevention, work flow and evidence-based practice, fall assessment

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