Reducing Falls in the Cardiac Care Unit: An Improvement Project
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Course Name
Clinical Improvement Project II CAPSTONE
Graduation Year
8-2026
Faculty Advisor
Jennifer Tudor
Abstract
Abstract
Background: Patient falls persist as a leading cause of preventable harm in hospitals, particularly among cardiac care patients who are at increased risk because of medication effects and mobility limitations. Despite existing fall `prevention measures in the Cardiac Care Unit (CCU) at Sutter Medical Center, Sacramento, 43 falls occurred, highlighting the need for improved patient education and consistent staff communication.
Purpose: This quality improvement project evaluated the effectiveness of implementing a standardized fall prevention communication script to reduce the average monthly fall rate in the CCU from 3.583 to fewer than 2 falls per month.
Methods: Using the Plan-Do-Study-Act (PDSA) framework, a standardized communication script was integrated into ambulation assistance and patient education over a six-week implementation period (May-June 2026). The script was provided to staff through pre-shift huddles, staff meetings, unit emails, and one-on-one rounding. Outcome measures included total monthly falls and falls per 1,000 patient days, using de-identified incident report data.
Results: Before the implementation period (January 1-May 19, 2026), the CCU recorded 18 falls, with an average of 3.16 falls per 1,000 patient days. Following implementation (May 19-June 30, 2026), the fall rate decreased to 1.82 falls per 1,000 patient-days, representing an approximate 42% reduction. June recorded only one patient fall, meeting the project’s goal of reducing monthly falls to fewer than two.
Conclusion: The standardized fall prevention communication script was a practical, low-cost intervention that integrated easily into existing nursing workflows and was associated with improved fall outcomes. Continued leadership support, staff education, and ongoing monitoring may improve sustainability, while future quality improvement efforts should evaluate the intervention over longer implementation periods.
Keywords
Falls, Communication, Scripting
Recommended Citation
Otero, Andrea; Campa, Aryanna; and Butac, Nia, "Reducing Falls in the Cardiac Care Unit: An Improvement Project" (2026). ELMSN E-Portfolio. A collection of Scholarly and Creative Works. 48.
https://scholarlycommons.pacific.edu/nursing-portfolios/48
