SAFETYLIT WEEKLY UPDATE

We compile citations and summaries of about 400 new articles every week.
RSS Feed

HELP: Tutorials | FAQ
CONTACT US: Contact info

Search Results

Journal Article

Citation

Sluggett JK, Lalic S, Hosking SM, Ilomӓki J, Shortt T, McLoughlin J, Yu S, Cooper T, Robson L, Van Dyk E, Visvanathan R, Bell JS. Aging Clin. Exp. Res. 2019; ePub(ePub): ePub.

Affiliation

Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.

Copyright

(Copyright © 2019, Holtzbrinck Springer Nature Publishing Group)

DOI

10.1007/s40520-019-01407-z

PMID

31728845

Abstract

BACKGROUND: Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. AIMS: To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance.

METHODS: An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance.

RESULTS: Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services.

CONCLUSIONS: This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.


Language: en

Keywords

Falls; Hospitalisation; Long-term care; Nursing home; Residential aged care; Root cause analysis

NEW SEARCH


All SafetyLit records are available for automatic download to Zotero & Mendeley
Print