Use of Root Cause Analysis to Prevent Falls and Promote Patient Safety in Clinical Rehabilitation Introduction
This study was performed to explore the root causes of patient falls by applying Root Cause Analysis and determine the implement procedures to prevent them. The author conducted root cause analysis retrospectively using comprehensive error review to determine and correct the causes of errors in the department of Physical medicine and rehabilitation of a medical center in Taiwan. The incidence and complications of patient falls were measured before and after conducting root cause analysis. The results of this study indicated that there is a decrease in annual incidence of falls from 4.8 per 100,000 subjects to 1.9 and 0.9 during the next two years of follow …show more content…
Each of the falls process was recorded immediately and reported during the next meeting which are graphically represented including all the possible links that influence the incidents. Moreover, the author developed a casual tree to clarify the possible reasons that may result in falls and reactive barriers were then developed. Also, several improvement measures were adopted during meetings to the see the notable change in the number of patient falls and to enhance the patient safety measures. The study examined falls over a period of one year with a follow up done up to two years which aids in analysing the effect of conducting RCA. This study not only examined the number of cases reported during follow up, but also examined the complications of falls before and after conducting RCA which adds a note on patient safety measures considered by the
This study was performed to explore the root causes of patient falls by applying Root Cause Analysis and determine the implement procedures to prevent them. The author conducted root cause analysis retrospectively using comprehensive error review to determine and correct the causes of errors in the department of Physical medicine and rehabilitation of a medical center in Taiwan. The incidence and complications of patient falls were measured before and after conducting root cause analysis. The results of this study indicated that there is a decrease in annual incidence of falls from 4.8 per 100,000 subjects to 1.9 and 0.9 during the next two years of follow …show more content…
Each of the falls process was recorded immediately and reported during the next meeting which are graphically represented including all the possible links that influence the incidents. Moreover, the author developed a casual tree to clarify the possible reasons that may result in falls and reactive barriers were then developed. Also, several improvement measures were adopted during meetings to the see the notable change in the number of patient falls and to enhance the patient safety measures. The study examined falls over a period of one year with a follow up done up to two years which aids in analysing the effect of conducting RCA. This study not only examined the number of cases reported during follow up, but also examined the complications of falls before and after conducting RCA which adds a note on patient safety measures considered by the