Citation

Lee A, Mills PD, Watts BV. Gen. Hosp. Psychiatry 2012; 34(3): 304-311.

Affiliation

Veterans Affairs National Center for Patient Safety Patient Safety Fellowship, White River Junction VA Medical Center, White River Junction, VT 05009, USA.

Copyright

(Copyright © 2012, Elsevier Publishing)

DOI

10.1016/j.genhosppsych.2011.12.007

PMID

22285368

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.

Language: en