Leadership Studies Commons^™

No Pass Zone: Preventing Patient Falls, Rheea Fe Bustos

Master's Projects and Capstones

Problem: According to the Agency for Healthcare Research and Quality (AHRQ), an estimated 700,000 to 1,000,000 inpatient falls occur in the United States every year. Context: In an August 2017 observation of bed alarm activations in patients’ rooms, it was noted that there was no designated staff member to answer alarms. This causes a delayed response time, which can result in patient falls. The root cause involved unclear expectations regarding what staff members are responsible for answering alarms. Interventions: Standard work was created to have the closest available person respond to the patient’s bed alarm. Initial implementation began in the …