Medicine and Health Sciences Commons^™

Purposeful Rounding For Fall Reduction, Deborah Grant Rn

Master's Projects and Capstones

Objective. The quality improvement project aimed to study the effects of purposeful rounding on falls in a long-term care unit. The focus was on CNAs who provided care for 6 residents each, with a current census of 36 residents in the long-term care setting. Problem. Many of the residents are at risk for falls due to immobility, medication, and environmental hazards (Centers for Disease Control and Prevention, 2022). Context. Research has found that the key reasons residents call for staff include needing to use the bathroom, to address pain, to address positioning, and to address IV pumps and alarms (Studer …

Implementing A Bedside Rounding Tool To Reduce Inpatient Falls, Steven W. Garcia

Master's Projects and Capstones

Problem: Each year, thousands of patients sustain falls while hospitalized, resulting in an increase in serious injuries or death. In a Neuroscience Step Down Unit (NSDU), fall rates in 2022 were higher than the NDNQI benchmark. Despite a thorough fall prevention policy, nurses inconsistently implemented preventative interventions, resulting in increased falls.

Context: The NSDU is a 15-bed inpatient unit providing intermediate-level care for patients with neurological and neurosurgical diagnoses. The unit is part of a 459-bed academic medical center and safety net hospital providing tertiary and quaternary care in southern California.

Interventions: A bedside safety rounds checklist for charge nurses …

Decreasing Patient Fall Rates In The Microsystem, Kevin Dwayne Sanchez Camaya

Master's Projects and Capstones

Abstract

Problem: Falls are considered never events, yet continuously occur in the inpatient setting. Falls,

especially falls with injuries, impact the patients, the staff, and the hospital. Falls cause extended lengths of stay, affect the morale of the patients and the staff, and are non-reimbursable events.

Context: There have been an increased rate of falls within a medical/surgical/telemetry unit

microsystem at a Northern California hospital despite standardized screening and prevention tools. The unit can house up to 52 patients and is the designated Covid unit of the hospital at the time of this project.

Interventions: The interventions include optimizing the …

Community-Dwelling Older Adult Fall Prevention Improvement Project, Evan Edminster Bsn, Rn, Cfrn, Tcrn, Cen, Nhdp-Bc

Master's Projects and Capstones

Abstract

Problem: Ground-level falls among community-dwelling adults 60 years and older are significant and contribute to adverse health outcomes such as fractures, functional decline, disability, and death. Additionally, falls among community-dwelling older adults are the number one mechanism of injury seen at a Northern California Level II trauma center. Falls often lead to post-fall fear, activity restriction, and physical deconditioning, further compounding fall risk.

Context: When trauma centers provide targeted outreach and screening for unmanaged health risks such as falls, they reduce unnecessary disability and premature death in the local population. Reducing total fall victim numbers and fall recidivism also …

The Fall Free Zone, Brendalyn Malimban

Master's Projects and Capstones

The fall prevention project is designed to decrease fall rates in the medical-surgical units by promoting accuracy in identifying fall risk patients and engaging patients in participating with their own safety. The project will follow Kotter’s change model to address the urgent need for reducing fall rates (Webster & Webster, 2018). A falls taskforce committee is already in place pursuing the goal mentioned. Engaging the staff members and leaders will be accomplished through reeducation of policies and procedures, admission process and the accurate use of the SCHMID Assessment Tool. These will take place during staff meetings, huddles and roving learning …

Combining Patient-Centered-Care And Technology To Reduce Falls In A Medical/Telemetry Unit, Megan Mira

Master's Projects and Capstones

Abstract

PROBLEM: From October 2017 through June 2018 there were 25 patient falls recorded on the 5^th floor medical surgical telemetry unit. Top factors contributing to this high fall rate include: poor patient-centered-care planning, and inadequate set-up for use of technology.

CONTEXT: According to the Joint Commission, 2015, each fall with injury costs $14,000. This estimate doesn’t include the potential indirect costs that account for the long-term effects of injuries such as disability, dependence on others, lost time from work, household duties, and reduced quality of life.

INTERVENTIONS: Staff education was introduced and focused on using a new mindfulness …

Introduction Of Communication Strategies To Decrease Patient Falls In An Acute Rehabilitation Setting, Alicia Joachim

Master's Projects and Capstones

Background: Due to the lack of appropriate fall prevention measures in an acute rehabilitation unit, there has been a notable increase of patient fall occurrences within a 6 month period. The purpose of this practice improvement project was to reduce patient falls within a 36-bed unit, using visual aids and effective communication among nursing staff. The multi-disciplinary members involved licensed nurses, nursing assistants, nursing supervisors, director of nursing, and executive administrator. Methods: The method used to implement this project included a literature search, informational interviews and staff surveys, and prioritization of interventions by the team. Project implementation was guided by …

Multifarious Interventions To Reduce Falls On The Medical-Surgical Units, Wenjie Ying

Master's Projects and Capstones

The CNL project was conducted on the 56-bed adult medical-surgical units in a trauma center. There were total eight fall incidences from January to February. The SWOT analysis, stakeholder analysis, pre-educational survey, cost-effective analysis and root-cause analysis suggested in-depth training on multifaceted fall prevention. The objectives include reducing falls by 50%, increasing staff’s adherence to fall prevention protocols, boosting staff’s confidence in patient mobility, improving staff responsiveness and communication with meds in HCAHPS, and enhancing knowledge of medications’ side effects by May 14, 2018. The literature reviews indicated that the multicomponent preventative measures to prevent falls along with leadership supports …

Assessment Of Fall Protocol Use On A Medical-Telemetry Unit, Ashia Mar

Master's Projects and Capstones

Purpose: This quality improvement project serves to implement a fall prevention plan to decrease patient falls on the medical-telemetry unit of a large metropolitan hospital.

Background: Patient falls are a persistent nationwide problem in the acute care setting. Between 700,000 and 1,000,000 falls occur in hospital every year and approximately 30-35% of these falls result in injury and 11,000 falls result in death (Health Research & Educational Trust, 2016). Falls always cause harm to the patient, whether it is emotional or physical; but, falls can also cause harm to the providers, family, and organization. Patient injury, additional hospital expenses, and …

Fall Prevention Protocol In Acute Care Setting, Allie Di Angelo

Master's Projects and Capstones

Purpose:

Purpose: The purpose of this quality improvement project is to implement a falls intervention to improve falls on the Medical Telemetry unit in the large metropolitan hospital.

Background: Between 700,000 and 1,000,000 falls occur in hospitals every year. Furthermore, approximately 30-35% of these falls result in injury and 11,000 falls result in death (Health Research & Educational Trust, 2016). Falls harm patients, families, and providers. They are also a high cost, as many insurance companies will not reimburse care when a patient falls. As a hospital organization it is important to ensure funds are going to the appropriate places. …

Assessment Of Falls Protocol Use On Medical-Telemetry Units, Fanny Ku

Master's Projects and Capstones

Purpose: The purpose of this quality improvement project is to identify a root cause analysis for an increase in falls at a large, metropolitan hospital and implement interventions designed to reduce the incidence of falls on the medical-telemetry unit.

Background: Falls, regardless of severity, may inflict irreparable consequences on patients, families, and hospitals. Approximately 20-30% of falls result in physical or emotional harm, including minor bruises, emotional trauma, and fractures (“Falls,” 2004). When falls occur, hospitals are generally responsible for all costs incurred from the sentinel event, and do not receive re-imbursement from insurances for services provided. In the large, …

Fall Prevention In The Inpatient Setting, Verna Bautista

Master's Projects and Capstones

Fall Prevention in the Inpatient Setting Abstract

This project focuses on patient and family fall prevention education through an educational brochure. 4South is a mixed medical/surgical and medical/surgical-telemetry unit, specializing in dialysis and stroke patients. Since January 2017, there has been eight falls on the unit. The project’s objective is to decrease the number of falls in 4South by 50% by the end of the 4^th quarter 2017.

An identified weakness was inconsistent patient and family education. The CNL roles of data analyst and clinician were utilized. With the feedback from the Fall Task Force committee, an educational brochure …

Fall Prevention: Responder 5 Bed Connectors, Ani Tatevossian

Master's Projects and Capstones

This paper explores falls, a sentinel event plaguing hospitals in the United States and internationally. Falls are a major contributor to negative patient outcomes and a source of financial strain for hospitals. One particular fall prevention intervention, Responder 5 bed alarms, was explored. A literature review on falls was conducted to study the effectiveness of bed alarms. Capezuti et al. (2009) found bed alarms to be error prone and stress the importance of patient risk factor assessment and using bed alarms as a multifactorial approach to fall prevention. Shorr et al. (2012) came to a similar conclusion after conducting a …

Fall Prevention Through Proactive Toileting, Kristin Smith

Master's Projects and Capstones

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 …