Getting to the Root of Falls: Use of a Mini-Root Cause Analysis Tool

Purpose:
The goal of this strategy was to determine the causes for in-patient falls that could not be clearly identified solely by our event reporting system.

Significance:
Nationwide,falls continue to be a problem leading to injury, and sometimes, death in acute care hospitals. Efforts to identify the causes of falls and interventions to decrease falls have met with limited success both in our institution and at others across the country.

Strategy and Implementation:
At our institution, identifying the causes for our falls was difficult and it was assumed that each speciality unit might have different reasons for falls. One method for analyzing the causes of falls in our organization was the "post fall huddle" form. This form allows for the immediate identification of circumstances surrounding a fall. The post fall huddle form is used as a mini-root cause analysis tool at the time of the fall and immediately gathers the individuals involved so that strategies for fall prevention can be implemented. Two units with high fall rates used this tool consistently for each fall.

Evaluation:
The use of this form has identified unit specific causes for falls allowing the implementation of individualized interventions. Each completed form was evaluated and common themes emerged that were unit specific.

Implications for Practice:
Nursing units that have consistently used this form have been able to develop specific interventions appropriate to their patient population to prevent further falls. This form may be useful in other hospitals to further elucidate the causes of falls and interventions to prevent them.