Root Cause Analysis of A Case of Femoral Neck Fracture Caused by Falls

Introduction：Fall prevention is one of the important issues that received attention in patient safety incidents of healthcare facility. Fall can cause varying degrees of injury, prolonged hospital stay and other complications such us bruises, contusions, brokenbones, head injuries and even death.

Methods：A brief description of the situation. All the process of the event is concisely recorded in the event description table, thenthe process is disassembled into detailed steps and the original appearance and traceability of the event are presented with a flow chart(Figure 1). Use a fishbone diagram(Figure 2) to analyze the cause of an event. Root cause analysis was carried out. Patientfactors: old age, weakness of both lower limb, previous falls at home, lack awareness of injuries caused by falls, poor compliance with preventive measures, no sense of old age, aging physical condition and limited mobility. Accompanying factors: Accompanyingdidn’t aware the importance of preventing falls. Nursing staff factors: Nursing guidance on fall prevention has been given when entering he ward by putting the nursing bell and daily necessities within reached, instructing patients to use the nursing bell, turning on the bed warning system and make sure its function normal but not review the accompanying implementation of fall preventionmeasures correctly.
Result：Identify root causes of events：patients factors, accompanying factors, nursing staff factors, equipment factors. Improvement measures：(1)For those who are classified as high-risk groups of falls by admission assessment, emphasizing their physical limits and the necessity of being accompanied at all the time when getting out of bed. (2)Make sure that the caregiver aware of the potential seriousness of falls and let them know the fall prevention measures. (3)Hold a cross-team meeting and invite the occupational therapists to instruct nursing staff and caregivers some strengthening exercises for patients with lower extremity weakness. (4)Contact the engineer to find out the reason why the bed warning system malfunctioned. (5)When accompanying patient leave for a while, the nursing staff should be notified, the nursing bell must be placed within reach and the rails should be pulled completely. (6)Nursing staff should evaluate the effect of fall prevention guidance and the implementation. (7)Check the function of bed waring system routinely.
Conclusion：It is hoped that through the project process, the incidence of falls and injuries can be reduced and the quality of care can be improved.
Root Cause Analysis of A Case of Femoral Neck Fracture Caused by Falls
Ya-Jyun,TangHui-Mei, HuangShu-Chen, Liao
Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan