Medicine and Health Sciences Commons^™

Implementing The Fall Tips Tool To Reduce Falls In Older Adults, Ruth C. Santiago

Master's Projects and Capstones

Problem: In many organizations, falls and associated major injuries create a large barrier to maintaining patient safety. Patient falls impact quality of care and create financial difficulty for all parties involved. It is important that prevention measures are effective and individualized.

Context: A significant increase in falls and major injuries have been documented in unit F1 of Facility A in Northern California. Current strategies to prevent falls have not been successful in reducing fall rates over the past year.

Interventions: The intervention to decrease falls on this unit is the Fall Tailoring Interventions for Patient Safety (TIPS) tool. The tool …

Reducing Care Companion Utilization In Medical-Surgical And Telemetry Units, Mary Jane B. Sagabaen

Master's Projects and Capstones

Abstract

Problem: The facility highly utilized sitters or care companions, negatively impacting the staffing plan, budget, and productivity. An average of 56 hours of care companions were used daily. This greatly exceeded the budget of 33 hours a day. Reassigning Patient Care Technicians (PCT) as care companions resulted in inadequate nurse support for patient care and increased cost for additional staffing needs. Despite this, the fall rate remained higher than the target.

Context: The patient population is mainly 65 years old and above, sometimes with confusion, dementia, delirium, and at high risk for falls and elopement. The culture included promptly …

Standardizing The Bedside Shift Report: Improving Communications And Promoting Patient Safety, Chona C. Alforque

Master's Projects and Capstones

PROBLEM: Nursing shift reports are integral to nursing as they allow for the transfer of critical information and responsibility of patient care from one nurse to another. Ineffective communication during shift-to-shift reports can contribute to gaps in patient care and breaches in patient safety, including medication errors, falls, and sentinel events. The greatest risk of communication breakdown is during transitions in care.

CONTEXT: St. Louise Regional Hospital, a small community hospital, consisting of an eight-bed medical-surgical intensive care unit lacked structure in how handoff should occur and had variances in shift handoffs. Observation of the shift handoff at the nurses’ …

Implementing A Fall Prevention Program: A Quality Improvement Project To Promote Patient Mobility On The Medical-Surgical Unit, Alba Araiza

Master's Projects and Capstones

Implementing a fall prevention program is imperative in acute healthcare settings. Falls are one of the top reported events that occur in hospitals and it is a patient safety concern that requires the implementation of evidence-based practices to reduce falls. This quality improvement project will be developed by a master’s prepared clinical nurse leader (CNL) on a medical-surgical unit to improve patient safety.

Problem

Maintaining patient safety is the most important priority in health care. Health care organizations implement protocols, policies and procedures to ensure that care is provided in a safe manner to minimize preventable harms. However, falls are …

Implementing A Fall Prevention Program: A Quality Improvement Project To Promote Patient Mobility On The Medical-Surgical Unit, Alba Araiza

Master's Projects and Capstones

Abstract

Implementing a fall prevention program is imperative in acute healthcare settings. Falls are one of the top reported events that occur in hospitals and it is a patient safety concern that requires the implementation of evidence-based practices to reduce falls. This quality improvement project will be developed by a master’s prepared clinical nurse leader (CNL) on a medical-surgical unit to improve patient safety.

Problem

Maintaining patient safety is the most important priority in health care. Health care organizations implement protocols, policies and procedures to ensure that care is provided in a safe manner to minimize preventable harms. However, falls …

Increasing Patient Safety During Medication Administration, Vivien Tso

Master's Projects and Capstones

Medication administration error is one of the crucial medical errors that compromises patient safety in hospitals each day. Direct observations were conducted to assess medication administration (MA) accuracy and practices in order to determine the root cause(s) of errors at a community-based, non-profit hospital. Failure to scan patients’ wristbands, to verbally verify patients’ identity with two identifiers, and to verbally verify patients’ allergies, were some practices that were found to lead to medication administration errors. Implementation tools such as an informative video and reminder signage at bedside computers were piloted at the oncology unit of the hospital to improve nursing …

The Effects Orthostatic Hypotension Has On Falls: A Study Done In San Francisco With The Patient Population Of The Veterans Affairs Hospital, Sherry A. Ballard Ms.

Master's Projects and Capstones

The Effects Orthostatic Hypotension has on Falls: A Study Done in San Francisco Represented

Population of the Veterans Affairs Hoapital

The global AIM of this project is to Identify patients that are at risk for Orthostatic Hypotension (OH) with in the first 24 hours of addmission. It was identified that 50% of the falls over the last 4 quarters at the VA were OH related. The patients were not identified as a fall risk and over half of them had fallen multiple times. After performing a nursing survey online, a SWOT analysis, and a Root Cause Analysis using a fishbone …

Establishing A Patient Safety Pilot Program In Ucsf Medical Center – Benioff Children’S Hospital: Principles, System Analysis, And Initial Steps, Paige Porter

Master's Projects and Capstones

Patient safety is a serious public health issue impacting individuals in all healthcare settings. UCSF Medical Center is a leading healthcare organization in San Francisco, dedicated to providing the safest and highest quality care to its patients. In an effort to further promote patient safety, the Family Escalation Project was created to enhance the communication between patients, families, and healthcare providers in the UCSF Benioff Children’s Hospital. This project was created in response to an adverse event in which a safety concern was not appropriately escalated. The goal of the project is to create a mechanism for patients and families …

Improving Patient Safety Through Accurate Medication Reconciliation, Dominique Watt

Master's Projects and Capstones

Medication errors due to incorrect medication reconciliation are a very present and serious problem in our microsystem. As an preop/postop outpatient unit, we see an average of 50 patients daily and perform medication reconciliations regularly. The problem is our nurses perform this task inconsistently and often incomplete, leading us to potential medication errors. During my CNL project, I worked with a committee of staff champions and developed a standard work guide for nurses to use in order to effective reconcile patient medications. We used fishbone diagrams, audit tools, surveys and led regular discussions in our huddles in order to develop …

Barriers Encountered By Nurses And Nursing Assistants That Prevent Purposeful Rounding, Mar Joseph B. Odias

Master's Projects and Capstones

Purpose: The aim of the study was to identify barriers encountered by registered nurses (RNs) and nursing assistants (NAs) that prevent purposeful (hourly) rounding.

Background: The literature has shown that purposeful rounding improves patient outcomes and safety. However, few studies show the barriers encountered by nursing staff that hinder the purposeful rounding process.

Methods: A pre-post test design was implemented on a 25-bed oncology, urology medical surgical unit with a staff of 38 RNs, 9 NAs, and 4 Unit Secretaries (US). A pre-implementation needs assessment survey was completed by 55% (21/38) of RNs, 33% (3/9) of NAs, and 100% (4/4) …

Relocation Of Orc To Or2, Svetlana N. Schopp

Master's Projects and Capstones

The goal of this Clinical Nurse Leader (CNL) internship project was to maintain safety and quality of care of obstetric (OB) patients undergoing Cesarean Sections (C/S) after operating room for cesarean sections (ORC) is relocated from obstetric unit to the main operating room (OR). The microsystem will accomplish this through effective teamwork, clear interdisciplinary communication, collaboration, and standardization of processes involved. The institution is a not for profit rural health care facility and is a designated Critical Access Hospital; it is located in Northern California. A general obligation bond was passed in 2007 to fund seismic upgrades. Old OB unit …