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Course Name
Clinical Improvement Project II CAPSTONE
Graduation Year
12-2025
Faculty Advisor
Dian Baker
Abstract
Background: In 2024, Sutter Medical Center Sacramento (SMCS) reported 17 patient falls in the Emergency Department (ED) lobby, with 94% (n = 16) occurring in the triage area. Patients awaiting placement after triage are not classified as admitted and thus are not included in CMS’s inpatient fall reporting program. However, due to the known safety risk, SMCS ED leadership began tracking lobby falls locally and partnered with University of the Pacific nursing students to address this issue.. Aim: This quality improvement project aimed to reduce the incidence of falls in the ED lobby through enhanced fall risk identification, timely reassessment, and improved patient education. The project aligned with Sutter’s mission to prioritize safety and minimize preventable harm. Methods: The quality improvement project was conducted in the ED lobby at SMCS. Patients were screened at triage using the Hester Davis Scale, and those deemed high-risk received a yellow fall risk bracelet and bilingual educational pamphlets developed and validated using the Patient Education Materials Assessment Tool (PEMAT). The intervention included: (1) targeted staff education delivered during ED shift huddles, (2) continuous reassessment of fall risk every two hours, and (3) the use of visual reminders to prompt patient safety behaviors. University of the Pacific nursing students monitored implementation through distribution logs and informal observations. Results: In 2025, four falls were reported in the lobby, occurring in February, March, April, and September. Three of these incidents occurred earlier in the year, and one occurred later. Year-to-date shows 29 total falls, with lobby falls accounting for 14% of the total, down from 17 in 2024. Conclusion: The project reinforced the importance of reassessing fall risk in not formally admitted ED patients. Interdisciplinary collaboration contributed to improvements in lobby safety practices and highlighted opportunities for future system-level interventions. Local tracking of lobby falls, although not mandated by CMS, provided valuable data to inform safety efforts.
Keywords
Emergency department, fall prevention, Hester Davis, triage, lobby safety, reassessment, quality improvement
Recommended Citation
Rodriguez Duarte, Tanya; Espino, Vaneza; Hayer, Roshni; and Mendoza, Yajari, "Fall Prevention in the Lobby of the Emergency Department at Sutter Medical Center Sacramento" (2025). ELMSN E-Portfolio. A collection of Scholarly and Creative Works. 35.
https://scholarlycommons.pacific.edu/nursing-portfolios/35
