Citation

Soncrant C, Neily J, Bulat T, Mills PD. J. Nurs. Care Qual. 2019; ePub(ePub): ePub.

Affiliation

Veterans Health Administration, National Center for Patient Safety, White River Junction, Vermont (Mss Soncrant and Neily and Dr Mills); Veterans Health Administration, VISN 8 Patient Safety Center of Inquiry, Veterans Affairs Medical Center, Tampa, Florida (Dr Bulat); University of South Florida Morsani College of Medicine, Tampa (Dr Bulat); and The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire (Dr Mills).

Copyright

(Copyright © 2019, Lippincott Williams and Wilkins)

DOI

10.1097/NCQ.0000000000000408

PMID

30998559

Abstract

BACKGROUND: Injurious falls continue to challenge health care. Causes of serious falls from the largest health care system in the United States can direct future prevention efforts.

PURPOSE: This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events.

METHODS: We categorized root cause analysis (RCA) reports and coded injury type, fall type, location, and root causes. We describe interventions during the fall and provide resources for future prevention.

RESULTS: There were 154 reported fall RCAs during this time. Most (83%, n = 128) resulted in major injury: hip fractures (43%, n = 66), other fractures (25%, n = 38), and head injury (16%, n = 24). Most falls were unwitnessed (75%, n = 116).

CONCLUSIONS: Patients who fell were not wearing hip or head protection. Most falls were unwitnessed, and none were on 1:1 observation. Such interventions may help prevent future injurious falls.

Language: en