Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.

Christina M. Soncrant; Lisa J. Warner; Julia Neily; Douglas E. Paull; Lisa Mazzia; Peter D. Mills; William Gunnar; Robin R. Hemphill

Commentary

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.

October 24, 2018

Soncrant CM, Warner LJ, Neily J, et al. AORN J. 2018;108(4):386-397.

View more articles from the same authors.

Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings. This quality improvement project applied the method to patient falls in Veterans Health Administration operating rooms and developed recommendations to guide improvement. Areas of focus included team communication, restraint use, and staff education. An Annual Perspective provides insights regarding how to enhance root cause analysis to help investigate incidents and improve care.

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