TY  - JOUR
PY  - 2012//
TI  - Using root cause analysis to reduce falls with injury in the psychiatric unit
JO  - General hospital psychiatry
A1  - Lee, Alexandra
A1  - Mills, Peter D.
A1  - Watts, Bradley Vince
SP  - 304
EP  - 311
VL  - 34
IS  - 3
N2  - 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>
LA  - en
SN  - 0163-8343
UR  - http://dx.doi.org/10.1016/j.genhosppsych.2011.12.007
ID  - ref1
ER  -