Date of Graduation

Fall 12-14-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr. Carlee Balzaretti

Second Advisor

Dr. Catherine Coleman


Falls are a leading cause of injury and death for adult males in the United States and have been an ongoing problem on the Medical Surgical Unit (MSU). Therefore, the aim of this project is to increase fall prevention education and communication on MSU in order to ultimately improve fall rates. Although there are currently fall prevention processes already in place, these may not be sufficient as demonstrated by recent fall metrics. Many RNs on MSU are fairly new nurses; and their enthusiasm and adaptability may be an advantage for this evidence-based project. Furthermore, the management team seems to be well respected and has already begun to facilitate a culture of safety over the last two years. Based on the gathered data and a literature review, it was obvious that staff and patient education and communication were the areas that needed to be addressed. Interventions were implemented in three phases that consisted of an educational in-service, a patient education sheet and contract, a communication board, and S.B.A.R. emails to staff. Pre-intervention data was gathered from multiple sources including the incident report system, the electronic health record (EHR), bedside audits, nurse surveys, and patient surveys. Data from the same sources will also be gathered post-implementation. There has been a downtrend of fall occurrences on MSU since the initiation of the interventions. The fall prevention team anticipates increased utilization of general prevention measures (bed alarm, patient belongings at bedside, etc.), increased staff awareness of the frequency of falls, improved nurse perception regarding the adequacy of patient fall education, and increased patient education. Through this project, the student was able to exercise the many different CNL roles in an environment he was unfamiliar with. By utilizing the proper frameworks, and with guidance and support from leadership, he was able to facilitate change by converting evidence-based literature into practice.