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University of San Francisco

Approach to Safety Improvement: Focusing on Better Care (Fall Prevention in Medical Surgical/Intermediate Care Unit)

Abstract

dc:description.abstract

<p>Patient safety is one of the major concern of any healthcare provider during their patient’s hospital stay. This project addressed the steady trend of fall incidences compared to last fiscal years’ data of an average of 4 falls per month. This trend created urgency to envisioned a plan for solutions to prevent this circumstance from happening. This Clinical Nurse Leader led a project in creating a process in identifying all patients that are high risk to fall (HRTF) prior to their admittance or transfer to Medical Surgical/Intermediate Care Unit and throughout their hospital stay until they are discharged. In addition, a fall prevention action plan was generated for all staff members to follow to ensure the safety of our patients. Kotter’s Eight-Step Process for leading change was utilized for this project. Several literature reviews revealed that incorporating patient-centered hourly rounding, discussion of HRTF patient during huddle time along with utilization of fall prevention methods were evident practices that should be implemented by all staff members to decrease falls within the microsystem. Since the implementation of fall prevention action plans, the microsystem remained on track in achieving its goal by decreasing fall episodes by 25% by the end of the 1<sup>st</sup> quarter (September 2016) compared from the previous quarters (July 2015 to June 2016). Fall Prevention Survey was conducted to evaluate the understanding and how the staff members were engaged in preventing falls. Eighty-five percent of staff members participated in the survey which had a positive perspective of the process in preventing falls. Through multiple cycles of PDSA, changes will be implemented accordingly in decreasing falls in the unit which led to improving patient care and efficiency and ultimately improved patient outcomes.</p>

Degree

thesis:*
Name thesis:degree_name
Master of Science in Nursing (MSN)
Level thesis:degree_level
Project/Capstone - Global access
Year dc:date.available
2016

Author and committee

dc:creator, dc:contributor.*
Author dc:creator
  • Caballes, Jose Fox, Jr
Contributors dc:contributor
  • Carlee Balzaretti
  • Dr. Elena Capella

Subjects

dc:subject × 7

Identifiers

dc:identifier.*
Repository record dc:identifier
https://repository.usfca.edu/capstone/369
OAI identifier oai:identifier
oai:repository.usfca.edu:capstone-1379

Chain of custody

source
Harvested from
University of San Francisco
Base URL
repository.usfca.edu/do/oai/
Last updated
2026-07-24
Source record
OAI-PMH GetRecord
citation

Caballes, Jose Fox, Jr. Approach to Safety Improvement: Focusing on Better Care (Fall Prevention in Medical Surgical/Intermediate Care Unit). Project/Capstone - Global access thesis, 2016. https://repository.usfca.edu/capstone/369