Using root cause analysis to reduce falls with injury in the psychiatric unit

General Hospital Psychiatry

Volumn 34, Issue 3, 2012, Pages 304-311

  Lee, Alexandra ^a   Mills, Peter D ^b,c   Watts, Bradley V ^b,c  

^a VA MEDICAL CENTER   (United States)

^b VA National Center for Patient Safety Field Office   (United States)

^c DARTMOUTH MEDICAL SCHOOL   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACCIDENTAL INJURY; ARTICLE; CONTROLLED STUDY; ENVIRONMENTAL FACTOR; FALL RISK; FALL RISK ASSESSMENT; FALLING; HEALTH CARE PLANNING; HEALTH HAZARD; HUMAN; INTEGRATED HEALTH CARE SYSTEM; INTERDISCIPLINARY COMMUNICATION; MEDICAL DOCUMENTATION; MENTAL HEALTH SERVICE; PATIENT SAFETY; PROTECTIVE EQUIPMENT; PSYCHIATRIC DEPARTMENT; RISK FACTOR; RISK REDUCTION; ROOT CAUSE ANALYSIS; STAFF TRAINING; TOTAL QUALITY MANAGEMENT;

ACCIDENTAL FALLS; DATABASES, FACTUAL; HUMANS; PSYCHIATRIC DEPARTMENT, HOSPITAL; ROOT CAUSE ANALYSIS; SAFETY MANAGEMENT; UNITED STATES; UNITED STATES DEPARTMENT OF VETERANS AFFAIRS; WOUNDS AND INJURIES;

EID: 84860374042     PISSN: 01638343     EISSN: 18737714     Source Type: Journal    
DOI: 10.1016/j.genhosppsych.2011.12.007     Document Type: Article

References (28)

1. Lavsa S.M., Fabian T.J., Saul M.I., Corman S.L., Coley K.C. Influence of medications and diagnoses on fall risk in psychiatric inpatients. Am J Health Syst Pharm 2010, 67(15):1274-1280.
2. Stevens J.A., Corso P.S., Finkelstein E.A., Miller T.R. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006, 12(5):290-295.
3. Rubenstein L.Z. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 2006, 35(Suppl 2):ii37-ii41.
4. Blair E., Gruman C. Falls in an inpatient geriatric psychiatric population. American Psychiatric Nurses Association 2006, 11(6):351-354.
5. Johal K.S., Boulton C., Moran C.G. Hip fractures after falls in hospital: a retrospective observational cohort study. Injury Int J Care Injured 2009, (40):201-204.
6. Morse J.M. Development of the morse fall scale. Preventing patient falls 2009, 113-115. Springer, New York. 2nd ed.
7. Joo J.H., Lenze E.J., Mulsant B.H., Begley A.E., Weber E.M., Stack J.A., et al. Risk factors for falls during treatment of late-life depression. J Clin Psychiatry 2002, 63(10):936-941.
8. Tinetti M.E. Clinical practice. Preventing falls in elderly persons. N Engl J Med 2003, 348(1):42-49.
9. Kuchnyka J., Kaser L., Wettstein A. Can falls in nursing homes be avoided?. Schweirzerische Rundschau fur Medizin Praxis 2004, (37):1503-1508.
10. Monane M., Avorn J. Medications and falls. Causation, correlation, and prevention. Clin Geriatr Med 1996, 12(4):847-858.
11. Howland R.H. Prescribing psychotropic medications for elderly patients. J Psychosoc Nurs Ment Health Serv 2009, 47(11):17-20.
12. Bloch F.M., Thibaud M., Dugue B., Breque C., Rigaud A.S., Kemoun G. Psychotropic drugs and falls in the elderly people: updated literature review and meta-analysis. J Aging Health 2011, 23(2):239-346.
13. Yates K.M., Creech Tart R. Acute care patient falls: evaluation of a revised fall prevention program following comparative analysis of psychiatric and medical patient falls. Appl Nurs Res 2010 Aug 3, [Epub ahead of print], doi:10.1016/j.apnr.2010.06.003.
14. Rogers P.D., Bocchino N.L. Restraint-free care: is it possible?. Am J Nurs 1999, 99(10):26-33.
15. Wu A.W., Lipshutz A.K. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008, 299(6):685-687.
16. Bagian J.P., Lee C., Gosbee J., DeRosier J., Stalhandske E., Eldridge N., et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001, 27(10):522-532.
17. Croteau R. Sentinel events, root cause analysis, and proactive risk reduction. Ambul Outreach 2009, 19-22.
18. Percarpio K.B., Watts B.V., Weeks W.B. The effectiveness of root cause analysis: what does the literature tell us?. Jt Comm J Qual Patient Saf 2008, 34(7):391-398.
19. The Joint Commission Sentinel event glossary of terms (last accessed January 11, 2011). http://www.jointcommission.org/SentinelEvents/se_glossary.htm.
20. Bagian J.P., Gosbee J. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv 2002, 28(10):531-545.
21. VHA national patient safety handbook 2008, Department of Veterans Affairs Veterans Health Administration, Washington, DC.
22. Bagian J.P., DeRosier J., Stalhandske E. Root cause analysis tools: actions and outcomes 2011, VA National Center for Patient Safety, http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-14 (last accessed January 14, 2011).
23. Gosbee J., McKnight S., Mannos D., Taylor L., Dropp K., Samples C. Primary analysis and categorization (PAC) glossary keyword categories and rules for applying them 2010, VA National Center for Patient Safety, Available at: http://www.patientsafety.gov/PACGlossary.pdf (accessed November 16, 2011).
24. VA National Center for Patient Safety Triage and triggering questions (last accessed January 14, 2011). http://www4.va.gov/NCPS/CogAids/Triage/index.html.
25. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966, 44((3): Suppl):166-206.
26. Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 2003, 15(6):523-530.
27. Palmer R.H. Using health outcomes data to compare plans, networks and providers. Int J Qual Health Care 1998, 10(6):477-483.
28. Mills P.D., Watts B.V., Miller S., Kemp J., Knox K., DeRosier J., et al. A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf 2010, 36(2):87-93.