@article{6128, author = {Alexandra Lee and Peter D. Mills and Bradley Watts V}, title = {Using root cause analysis to reduce falls with injury in the psychiatric unit.}, abstract = {

OBJECTIVE: The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reduce falls and injuries.

METHODS: A search of the Veterans Health Administration National Center for Patient Safety database was conducted to identify root cause analysis (RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 to March 2010 were included.

RESULTS: One hundred and thirty-eight actions were identified from the RCA reports. The most common activities the individual was engaged in during a fall included getting up from a bed, chair or wheelchair (21.3%); walking/running (10.7%); bathroom related (9.9%) or behavior related (9.9%). The most common root causes were environmental hazards (11.2%), poor communication of fall risk (8.9%), lack of suitable equipment (8.9%) and need for improvement of the current system for falls assessment (8.9%). Staff education (19.9%), development of tools to improve falls documentation (17.0%) and providing falls prevention equipment (14.2%) were the most frequent actions taken.

CONCLUSIONS: The results describe the location, activity and root causes surrounding falls that occur in psychiatric units resulting in injury, and provide some suggestions on how to implement a successful action plan.

}, year = {2012}, journal = {Gen Hosp Psychiatry}, volume = {34}, pages = {304-11}, month = {12/2012}, issn = {1873-7714}, doi = {10.1016/j.genhosppsych.2011.12.007}, language = {eng}, }