Megan Mira

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. Cathy Coleman

Second Advisor

Dr. Nancy Taquino



PROBLEM: From October 2017 through June 2018 there were 25 patient falls recorded on the 5th floor medical surgical telemetry unit. Top factors contributing to this high fall rate include: poor patient-centered-care planning, and inadequate set-up for use of technology.

CONTEXT: According to the Joint Commission, 2015, each fall with injury costs $14,000. This estimate doesn’t include the potential indirect costs that account for the long-term effects of injuries such as disability, dependence on others, lost time from work, household duties, and reduced quality of life.

INTERVENTIONS: Staff education was introduced and focused on using a new mindfulness script, combined with expectations for connecting all beds to the Responder 5 technology. An emphasis was placed on fall prevention conversations, which occurred during Nurse Knowledge Exchange (NKE) and Authentic Hourly Visits (AHV). Validation of these discussions were monitored through admission assessment documentation review and direct staff observation.

MEASURES: The expected outcome of the fall reduction project aimed for a 90% compliance with usage of the Mindfulness Script and the Responder 5 system. Daily audits for both interventions were performed by nursing leadership.

RESULTS: From July 2018-September 2018 there was a drastic reduction in falls; the rate decreased from 3 falls per month to 3 falls in 3 months, averaging 1 fall a month.

CONCULSION: Using a generalized risk stratification tool is inadequate to prevent falls, as it excludes some subsets of fall risk patients. By combining a risk assessment tool with standardized scripts, customized care plans, and integrating technology, a successful bundle for preventing falls was adopted in the medical telemetry unit.

Keywords: fall prevention, bundle, technology, mindfulness, risk stratification, patient-centered.

Included in

Other Nursing Commons