Date of Graduation

Summer 8-9-2019

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Cathy Coleman


Problem: Hospital falls are a growing national patient safety concern that cause anxiety, pain, distress, serious injuries, and increased health care utilization. Despite the presence of a well-developed falls prevention protocol since 2017. Internal data from an inpatient medical-surgical telemetry (MST) unit indicate the largest number of fall-related events among the hospital’s departments.

Context: Practice improvement project was initiated in a 217-bed community hospital to determine barriers and potential success factors. This MST is a dynamic, 48-bed unit providing care to mainly geriatric patients who require continuous telemetry monitoring and complex medical, trauma, and surgical services. Senior leaders in the hospital consider falls and fall-related injuries to be a top priority and therefore support the implementation for a cost-effective plan to improve clinical, quality, and fiscal outcomes.

Intervention: A unit based Clinical Nurse Leader (CNL) led the team to achieve the unit goal of a 20% reduction in falls by the end of the performance year 2019 utilizing improvement activities to foster the development of both a nursing and patient-centered approach. The primary intervention included the formation of a long-term Fall Prevention Safety Committee (FPSC) to develop, oversee and test a new and multifaceted intervention (or change package) consisting of several best practices. The re-introduction of a well-organized, committed fall prevention team was implemented to enhance the organizational infrastructure and oversight of unit-based fall prevention initiatives.

Measures: To evaluate the effectiveness of the FPSC and the change package, three “metrics that matter” were assessed including a quarterly patient and team satisfaction survey, monthly fall rates and an annual analysis of the MST fall rate. These metrics will continue to be monitored and compared with benchmarks and baseline data in order to assess progress toward a yearly reduction of 20% in fall rates.

Results: Implementation testing has been ongoing since June 03, 2019. Based on the preliminary data, the FPSC help reduced the rates of falls during the initial stage of the implementation testing through a collaborative team effort to identify problem areas and implement solutions. Only one fall event has occurred since the test of change began over 8 weeks. The change package significantly impacted the knowledge and behaviors of the staff, patients and their families, thus resulting in heightened awareness and engagement about fall prevention. The result is limited at this time; however, the change is clinically relevant and continues to trend downward.

Conclusion: Improving the identification of at-risk patients and decreasing falls is a complex process in the acute care setting. Lack of sustainable organization infrastructure contributes to inconsistent monitoring and interventions to ensure patient safety and decrease fall rates. Unit-based interprofessional teams that are highly motivated and well organized can significantly decrease fall rates through proactive approaches to anticipate risk and implement change strategies.