Date of Graduation

Summer 8-22-2019

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Susan Mortell DNP, RN, CNL

Second Advisor

Carla S. Martin MSN, RN, CIC, CNL


In the microsystem setting of this project, there have been two patient falls, within the last year. These falls did not result in injury, hence, did not create additional cost for the hospital, nor the patient. Evaluation of the patient’s charts concluded that the fall risk assessments for the patients in question were not entirely indicative of their risk for falls. Additionally, the fall risk care plans were not patient specific in that they did not fully address the designated fall risks of the patient. An abundance of evidence exists supporting the need to reduce falls, and that fall reduction can be attained by adequately assessing fall risk, as well as by care planning in a multidisciplinary manner. The aim of this project is to improve patient safety by reducing falls. To attain this goal, staff teaching was done regarding the necessity of patient-specific fall risk assessments, as well as care planning specifically for these individualized fall risks. The duration of the evaluation of the process began upon admission to the microsystem, and ended upon discharge from the same microsystem. The resulting conclusion of this process improvement project is projected to be that the fall incidence rate will be reduced to zero, and will remain at zero, through the end of the year. However, final outcomes remain pending.

Included in

Nursing Commons