Patient death resulting from a fall is one of the National Quality Forum’s “Never events” and death or serious disability resulting from a fall is also on the list of hospital-acquired conditions that Medicare/Medicaid will no longer reimburse for. For these reasons, as well as reasons of patient safety, healthcare facilities must work on reducing the risk of patients falling.
Because there are myriad ways a patient can have a fall, we will show an example of a specific case. In this case, a disoriented patient (who was considered a high fall risk) was left alone in an imaging room, without being strapped on, after radiographs were taken. The patient ruptured an eyeball, resulting in blindness in one eye. The medical facility involved received a fine of $25,000.
During the root cause analysis, the facility determined that the policies regarding high fall risks were not followed in this case. As a result, the facility has instituted safety education for the imaging staff, a monitoring process to ensure policies are being followed, and a program whereby a clinical staff member accompanies high fall risk patients to the imaging room. These are the solutions to the root cause analysis.
Although the analysis we performed is specific to this case, the solutions and thought process are not. To reduce falls, every facility should re-evaluate its fall risk program. Are the criteria still valid and being uniformly applied by all staff? Is there more that can be done to reduce the risk of falls? We can help you take a similar incident from your facility to help you improve safety processes.
Click on “Download PDF” above to download a PDF showing the Root Cause Analysis Investigation.
Return to Root Cause Analysis Healthcare Home Page