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PSNet: Patient Safety Network
Journal Article
Study

Using root cause analysis to reduce falls with injury in the psychiatric unit.

Lee A, Mills PD, Watts B. General hospital psychiatry. 2012;34:304-11.

This study reviewed 75 root cause analyses from the Veterans Health Administration system to highlight common activities during falls and frequent contributing factors. Getting up from a bed or chair was the most common activity, whereas environmental hazards and poor communication of fall risk were the most common contributing factors.