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 1st 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.
","abstract_html":"<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>","abstract_has_math":false,"creators":["Caballes, Jose Fox, Jr"],"institution":null,"degree_name":"Master of Science in Nursing (MSN)","degree_level":"Project/Capstone - Global access","degree_discipline":null,"degree_department":null,"school":null,"contributors":["Carlee Balzaretti","Dr. Elena Capella"],"advisors":[],"committee_chairs":[],"committee_members":[],"year":2016,"date_issued":"2016-12-16T08:00:00Z","date_published":"2016-12-16T08:00:00Z","updated_at":"2026-07-24T05:43:40Z","subjects":["Falls","Fall Prevention","Patient Safety","Patient-Centered Hourly Rounding","HRTF","Geriatric Nursing","Other Nursing"],"languages":[],"rights":[],"rights_urls":[],"identifier_entries":[]},"links":{"outbound_url":"https://repository.usfca.edu/capstone/369","outbound_label":"Repository record","outbound_source":"dc:identifier"},"metadata_groups":[{"id":"people","label":"People","entries":[{"key":"dc:contributor","label":"Contributor","values":["Carlee Balzaretti","Dr. Elena Capella"]},{"key":"dc:creator","label":"Author","values":["Caballes, Jose Fox, Jr"]}]},{"id":"academic_context","label":"Academic Context","entries":[{"key":"dc:date.available","label":"Dc Date Available","values":["2016-08-07T07:00:00Z"]},{"key":"thesis:degree_level","label":"Degree Level","values":["Project/Capstone - Global access"]},{"key":"thesis:degree_name","label":"Degree Name","values":["Master of Science in Nursing (MSN)"]}]},{"id":"subjects_keywords","label":"Subjects and Keywords","entries":[{"key":"dc:subject","label":"Dc Subject","values":["Falls","Fall Prevention","Patient Safety","Patient-Centered Hourly Rounding","HRTF","Geriatric Nursing","Other Nursing"]}]},{"id":"identifiers","label":"Identifiers","entries":[{"key":"dc:identifier","label":"Identifier","values":["https://repository.usfca.edu/capstone/369"]}]},{"id":"additional","label":"Additional Metadata","entries":[{"key":"dc:description.abstract","label":"Abstract","values":["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 1st 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.
"]},{"key":"dc:title","label":"Title","values":["Approach to Safety Improvement: Focusing on Better Care (Fall Prevention in Medical Surgical/Intermediate Care Unit)"]}]}],"canonical_facts":{"dc:contributor":["Carlee Balzaretti","Dr. Elena Capella"],"dc:creator":["Caballes, Jose Fox, Jr"],"dc:date.available":["2016-08-07T07:00:00Z"],"dc:description.abstract":["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 1st 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.
"],"dc:identifier":["https://repository.usfca.edu/capstone/369"],"dc:subject":["Falls","Fall Prevention","Patient Safety","Patient-Centered Hourly Rounding","HRTF","Geriatric Nursing","Other Nursing"],"dc:title":["Approach to Safety Improvement: Focusing on Better Care (Fall Prevention in Medical Surgical/Intermediate Care Unit)"],"thesis:degree_level":["Project/Capstone - Global access"],"thesis:degree_name":["Master of Science in Nursing (MSN)"]},"updated_at":"2026-07-24T05:43:40Z"}