@article{ref1,
title="Using root cause analysis to reduce falls with injury in the psychiatric unit",
journal="General hospital psychiatry",
year="2012",
author="Lee, Alexandra and Mills, Peter D. and Watts, Bradley Vince",
volume="34",
number="3",
pages="304-311",
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.<p /> <p>Language: en</p>",
language="en",
issn="0163-8343",
doi="10.1016/j.genhosppsych.2011.12.007",
url="http://dx.doi.org/10.1016/j.genhosppsych.2011.12.007"
}