Skip to main content

Using Aggregate Root Cause Analysis to Reduce Falls and Related Injuries

Buy Article:

$20.00 plus tax (Refund Policy)

Abstract:

Background: In certain categories of adverse events, Department of Veterans Affairs (VA) facilities may combine data to produce an aggregate review of the data. Individual root cause analyses are still required for the more serious adverse events. About 100 of the VA acute and long term care facilities contributed data to an analysis of results of 176 root cause analyses (RCAs) for patient falls occurring in the VA system.

Methods: Success was measured through a decreased report of falls and major injures due to falls after each organization's action plans were implemented. In addition, telephone interviews were conducted to understand success factors as well as barriers to implementation of clinical improvements.

Results: Of the 745 actions generated (that addressed the root cause), 435 (61.4%) had been fully implemented and another 148 (20.9%) had been partially implemented; 34.4% of the facilities reported reducing falls and 38.9% reported reducing major injuries due to falls.

Discussion: The action plans associated with these reductions focused on making specific clinical changes at the bedside rather than policy changes or educating staff. Specific interventions most highly associated with reductions in falls and injuries included environmental assessments, toileting interventions, and interventions that directly addressed the root cause and were the responsibility of a single person (as opposed to a group).

Document Type: Research Article

Publication date: January 1, 2005

More about this publication?
  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
  • Editorial Board
  • Information for Authors
  • Subscribe to this Title
  • Information for Advertisers
  • Reprints and Permissions
  • Index
  • Ingenta Connect is not responsible for the content or availability of external websites
jcaho/jcjqs/2005/00000031/00000001/art00004
dcterms_title,dcterms_description,pub_keyword
6
5
20
40
5

Access Key

Free Content
Free content
New Content
New content
Open Access Content
Open access content
Subscribed Content
Subscribed content
Free Trial Content
Free trial content
Cookie Policy
X
Cookie Policy
Ingenta Connect website makes use of cookies so as to keep track of data that you have filled in. I am Happy with this Find out more