Development Of A Fall Prevention Bundle With Evidence-Based Tools For Hospitalized Adults, Kelly A. Tirone

Master's Projects and Capstones

Problem

One million hospitalized people fall annually in the United States, and up to a third are preventable.

Context

Data from an acute care hospital show one medical-surgical unit reported eight patient falls in 2021, two causing major harm that reached sentinel event criteria.

Interventions

A Clinical Nurse Leader (CNL) leveraged the unique CNL skill set and characteristics of Human-Centered Leadership to engage in horizontal leadership, injury prevention, and team coordination through authentic human connection. The team leveraged documentation for improved fall risk communication. Unavoidable disruptions hindered other planned interventions.

Measures

Outcome measures observe for total fall count and the …

Save Lives And Sanitize: Prevention Of Surgical Site Infections Post-Cesarean Section Through Increased Hand Hygiene Compliance, Lindsay N. Nance

Master's Projects and Capstones

Problem: Surgical site infections (SSIs) occur in 3-15% of cesarean sections, making SSIs one of the most common hospital-acquired infections (HAIs). Surgical site infections (SSIs) have increased within a Labor & Delivery (L&D) unit in a large California teaching hospital for the past three years, affecting reimbursement and creating a range of adverse outcomes for patients. Performance of consistent and thorough hand hygiene practices is key to preventing infection, yet the unit’s hand hygiene compliance of 66.7% is well below the facility’s target goal of 90%. Based on recommendations from the organization’s Infection Prevention & Control (IPC) specialist, the …

Preventing Maternal Falls, Blair Burkhart

Master's Projects and Capstones

Patient falls are unfortunate events in healthcare that are an essential quality improvement focus during patients’ hospital stays. At Hospital X, a private institution located in the suburbs of a large city, there had been 23 maternal falls within the last three years. This increase in maternal fall rate puts this hospital’s maternity unit above the average of other hospital’s fall rates according to the National Database of Nursing Quality Indicators. This quality improvement project aimed to reduce the rate of maternal falls on postpartum units through various forms of staff education. Education included Morse Fall Scale scoring, Sara Stedy …

Reducing Postpartum Maternal Falls: A Quality Improvement Project, Sarah L. Iroz

Master's Projects and Capstones

Falls are an unfortunate, common occurrence in the healthcare system and are often not thought to be a problem in the obstetrics population. Key stakeholders in a Northern California hospital brought the issue of maternal falls to leaders of the quality improvement team on the maternity unit. In the last three years, there have been 23 falls on the maternity floor, making their fall rate above the national average. It is the purpose of this project to aid the quality improvement team in reducing postpartum maternal falls over the next three years. After conducting a unit assessment, performing a literature …

Safe Sleep In The Nicu Environment For Sids Prevention, Renee J. Aumua

Master's Projects and Capstones

Abstract

Sudden Infant Death Syndrome(SIDS) remains a leading cause of death for infants less than one year of age. Historically, Neonatal Intensive Care units have been exempt from following SIDS safe sleep guidelines recommended by the American Academy of Pediatrics(AAP) for SIDS prevention due to patient medical status and environment. However, in 2011 these guidelines were updated by the AAP to include NICU specific recommendations. This is a very important change due to this patient population being at a higher risk for SIDS than the term, well newborn. The Safe Sleep project was conducted in a 35 bed, tertiary care …