@article{ref1,
title="Recommendations for fall-related injury prevention: a 1-year review of fall-related root cause analyses in the Veterans Health Administration",
journal="Journal of nursing care quality",
year="2019",
author="Soncrant, Christina and Neily, Julia and Bulat, Tatjana and Mills, Peter D.",
volume="ePub",
number="ePub",
pages="ePub-ePub",
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. <br><br>PURPOSE: This article analyzes injurious falls in the Veterans Health Administration and provides generalizable recommended actions to prevent future events. <br><br>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. <br><br>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). <br><br>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.<p /> <p>Language: en</p>",
language="en",
issn="1057-3631",
doi="10.1097/NCQ.0000000000000408",
url="http://dx.doi.org/10.1097/NCQ.0000000000000408"
}