Date of Graduation

Summer 8-12-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Problem: According to the Agency for Healthcare Research and Quality (AHRQ), an estimated 700,000 to 1,000,000 inpatient falls occur in the United States every year. Context: In an August 2017 observation of bed alarm activations in patients’ rooms, it was noted that there was no designated staff member to answer alarms. This causes a delayed response time, which can result in patient falls. The root cause involved unclear expectations regarding what staff members are responsible for answering alarms. Interventions: Standard work was created to have the closest available person respond to the patient’s bed alarm. Initial implementation began in the Lombard unit. Ultimately, the project became called the No Pass Zone and all Med/Surg units and interdisciplinary teams were trained. Measures: The goal for the No Pass Zone will be to increase the use of standard work for answering bed alarms with any available staff member closest to the patient’s room responding and decrease bed alarm response times by less than 60 seconds 100% of the time. The global aim for the established falls program at ZSFGH, of which the No Pass Zone is a component, is to decrease falls with injury from 3.1 to 2.3 falls per monthby August 31, 2018. Results: After initial implementation in the Lombard unit, average bed alarm response times decreased and response times lasting more than 60 seconds were almost eliminated. Post intervention data after all Med/Surg units and interdisciplinary teams were trained showed the highest proportion of bed alarms lasting longer than 60 seconds occurred in the sitter and isolation rooms. The PDSA and bed alarm standard work were revised to include workflow to answer bed alarms in the sitter and isolation rooms. Staff members were educated on the revision. Post intervention data will be collected by the end of August 2018. Conclusions: Since the implementation of the falls program at ZSFG, the rate of patient falls has stabilized and continued to decrease during the No Pass Zone intervention period.