ID
M202610120921
Pathway
Health Systems Science
Description
Adult inpatient falls remain a major patient‑safety concern at UMass Memorial Medical Center, with 1,008 falls between May 2025–May 2026 and significant variation in fall‑prevention practices across units. Four high‑risk units—S5, 4E, S2, and 6E—accounted for 176 falls, including moderate and minor injuries. Despite existing policies, fall‑prevention steps are inconsistently applied, and caregivers report uncertainty about “the correct fall‑prevention steps for different patient scenarios” and limited real‑time reinforcement. This project aims to understand caregiver knowledge gaps in fall prevention by analyzing workflows, surveying interdisciplinary teams, and identifying root causes such as inconsistent mitigation, policy non‑adherence, and gaps in safe‑patient‑handling practices. Students will contribute to assist root cause analysis, data analysis, help develop intervention tools focused on fall prevention, and support implementation strategies that translate high‑level policies into clear, practical, unit‑specific actions. They will also have opportunities to participate in RCA reviews, and dissemination efforts.
Goals
1. Measure and analyze caregiver knowledge gaps in fall‑prevention practices across high‑risk and low‑risk units using surveys, Pareto analysis, and 5‑Why root‑cause methods.
2. Support development of targeted educational materials that reinforce safe mobilization, assistive‑device selection, and consistent implementation of fall‑prevention precautions.
3. Assist with unit‑level workflow improvements, including strengthening interdisciplinary communication (RN–PCA–PT/OT–physician), enhancing MDR discussions of high‑risk patients, and improving post‑fall huddle reliability.
4. Participate in data collection and analysis, including fall‑rate trends, MORSE/AMPAC monitoring, and evaluation of current-state workflows across RN, PCA, charge nurse, and provider roles.
5. Contribute to dissemination, including presentations, educational sessions, and potential scholarly outputs related to fall‑prevention interventions and caregiver competency improvement.
2. Support development of targeted educational materials that reinforce safe mobilization, assistive‑device selection, and consistent implementation of fall‑prevention precautions.
3. Assist with unit‑level workflow improvements, including strengthening interdisciplinary communication (RN–PCA–PT/OT–physician), enhancing MDR discussions of high‑risk patients, and improving post‑fall huddle reliability.
4. Participate in data collection and analysis, including fall‑rate trends, MORSE/AMPAC monitoring, and evaluation of current-state workflows across RN, PCA, charge nurse, and provider roles.
5. Contribute to dissemination, including presentations, educational sessions, and potential scholarly outputs related to fall‑prevention interventions and caregiver competency improvement.
Mentor
Sandhya Tagaram
Mentor E-mail
sandhya.tagaram@umassmemorial.org
Department
Hospital Medicine
Availability
Yes
Number Spots
2