Date of Graduation

Summer 8-7-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Taquino, Nancy


Problem: Inpatient falls are the top quality measure for patient safety in hospitals. In the United States, falls affect approximate one million people per year leading to increased health care utilization and cost. A Northern California Hospital 24-bed Medical-Surgical-Telemetry (MST) Unit has experienced high rates of patient falls in 2016 to 2017. Therefore, it is imperative that this hospital MST unit develop an effective fall prevention program.

Context: The MST is a 24-bed inpatient telemetry unit serving a population at risk for cardiovascular disease with patients primarily 65 years and older. The MST unit has also experienced a high turnover of unit managers impacting staff focus and awareness on daily nursing task rather than on patient centered-care and safety.

Interventions: The plan is to integrate a Clinical Nurse Leader (CNL) to establish an interprofessional team to reduce fall rate in the MST unit. The plan is to test this project that includes three components: 1) a quality improvement model, 2) a proactive risk assessment, and 3) standardized intentional rounding. The overall project aim is to lengthen the days between patient fall events and thereby reduce the incidence of falls per year. This project is currently in progress.

Measures: The outcome measures will include be the number of fall events in the unit per month and the average days between fall events. The process measures will include staff compliance to the steps for intentional rounding and be the number of compliance from each observation of staff on intentional rounding, and the balancing measure will be the result of the job satisfaction survey completed by the MST unit staff.

Results: Intervention testing started on October 31, 2017. Currently, there is not enough data to establish a trend, but the initial results show a positive outcome. So far, the average days between patient fall events have increased from baseline. There were only four fall events from January to June 2018 compared to 27 patient falls in 2017.

Conclusions: Based on the preliminary results, integrating the CNL using quality improvement science with a proactive approach assisted in the reduction of fall events per month in the MST unit. Moving forward, the CNL need to develop the unit champions to sustain this project. The team will need to continue post-fall huddles and discussing the various ways of preventing falls. This project demonstrates the impact of the Clinical Nurse Leaders who can accelerate the translation of evidence into practice and improve outcomes.

Included in

Nursing Commons