%0 Journal Article
%T Recommendations for fall-related injury prevention: a 1-year review of fall-related root cause analyses in the Veterans Health Administration
%J Journal of nursing care quality
%D 2019
%A Soncrant, Christina
%A Neily, Julia
%A Bulat, Tatjana
%A Mills, Peter D.
%V ePub
%N ePub
%P ePub-ePub
%X 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>
%G en
%I Lippincott Williams and Wilkins
%@ 1057-3631
%U http://dx.doi.org/10.1097/NCQ.0000000000000408