Date of Graduation

Fall 12-13-2014

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

T. Gallo


This paper will summarize the quality improvement falls prevention project conducted by a University of San Francisco Clinical Nurse Leader student. Falls in the hospital setting are an ongoing problem in our healthcare system as they have great physical and financial impacts (Salamon, Victory, & Bobay, 2012). Hospital A, an urban teaching hospital, uses the Schmid scale for determining if a patient is a fall risk which includes the assessment of need for ambulatory aids, history of falls, and impaired cognition among other criteria (Schmid,1990). Fall rates are climbing in the United States and the trend is similar on Hospital A’s hematology-oncology and BMT unit hereby referred to as Unit B. Because of the impact on patient safety, a falls prevention project performance improvement project was implemented. An assessment of Unit B’s needs, diagnosis of Unit B’s presenting problem, and the intervention implemented will be discussed followed by an evaluation with further recommendations. The implementation process and design of this paper follow the theory of change theories of Kurt Lewin and Ronald Lippitt (see Appendix A; Mitchell, 2013).