Health Scope

Published by: Kowsar

Root Cause Analysis of Falls Occurred and Presenting Fall Prevention Strategies Using Nominal Group Technique

Zhila Najafpour 1 , Ali Movafegh 2 , Arash Rashidian 3 , Mohamadreza Jafari 4 , Ali Akbari Sari 3 and Mohammad Arab 3 , *
Authors Information
1 Department of Health Care Management, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Tehran University of Medical Sciences, Tehran, Iran
3 School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
4 Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
Article information
  • Health Scope: November 2018, 7 (4); e12273
  • Published Online: October 27, 2018
  • Article Type: Research Article
  • Received: December 2, 2016
  • Revised: July 24, 2017
  • Accepted: July 30, 2017
  • DOI: 10.5812/jhealthscope.12273

To Cite: Najafpour Z, Movafegh A , Rashidian A, Jafari M, Akbari Sari A, et al. Root Cause Analysis of Falls Occurred and Presenting Fall Prevention Strategies Using Nominal Group Technique, Health Scope. 2018 ; 7(4):e12273. doi: 10.5812/jhealthscope.12273.

Abstract
Copyright © 2018, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
1. Background
2. Methods
3. Results
4. Discussion
Acknowledgements
Footnotes
References
  • 1. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, et al. The critical care safety study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694-700. doi: 10.1097/01.CCM.0000171609.91035.BD. [PubMed: 16096443].
  • 2. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the harvard medical practice study I. 1991. Qual Saf Health Care. 2004;13(2):145-51. discussion 151-2. doi: 10.1136/qshc.2002.003822. [PubMed: 15069223]. [PubMed Central: PMC1743811].
  • 3. von Renteln-Kruse W, Krause T. Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention. J Am Geriatr Soc. 2007;55(12):2068-74. doi: 10.1111/j.1532-5415.2007.01424.x. [PubMed: 17971140].
  • 4. Oliver D, Healey F, Haines TP. Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-92. doi: 10.1016/j.cger.2010.06.005. [PubMed: 20934615].
  • 5. Vassallo M, Vignaraja R, Sharma JC, Hallam H, Binns K, Briggs R, et al. The effect of changing practice on fall prevention in a rehabilitative hospital: The Hospital Injury Prevention Study. J Am Geriatr Soc. 2004;52(3):335-9. doi: 10.1111/j.1532-5415.2004.52102.x. [PubMed: 14962145].
  • 6. Koh SL, Hafizah N, Lee JY, Loo YL, Muthu R. Impact of a fall prevention programme in acute hospital settings in Singapore. Singapore Med J. 2009;50(4):425-32. [PubMed: 19421690].
  • 7. Fonda D, Cook J, Sandler V, Bailey M. Sustained reduction in serious fall-related injuries in older people in hospital. Med J Aust. 2006;184(8):379-82. [PubMed: 16618235].
  • 8. Amato-Vealey EJ, Barba MP, Vealey RJ. Hand-off communication: A requisite for perioperative patient safety. AORN J. 2008;88(5):763-70. quiz 771-4. doi: 10.1016/j.aorn.2008.07.022. [PubMed: 19024783].
  • 9. Loria G, Bhargava A. Prevention of patient falls – A case study. Apollo Med. 2013;10(2):175-80. doi: 10.1016/j.apme.2013.02.006.
  • 10. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors for falls in community-dwelling older people: A systematic review and meta-analysis. Epidemiology. 2010;21(5):658-68. doi: 10.1097/EDE.0b013e3181e89905. [PubMed: 20585256].
  • 11. Teixeira TC, de Cassiani SH. [Root cause analysis: Evaluation of medication errors at a university hospital]. Rev Esc Enferm USP. 2010;44(1):139-46. Portuguese. doi: 10.1590/S0080-62342010000100020. [PubMed: 20394231].
  • 12. Taylor-Adams S, Vincent C. Systems analysis of clinical incidents: The London protocol. Clin Risk. 2016;10(6):211-20. doi: 10.1258/1356262042368255.
  • 13. Schwendimann R, Buhler H, De Geest S, Milisen K. Falls and consequent injuries in hospitalized patients: Effects of an interdisciplinary falls prevention program. BMC Health Serv Res. 2006;6:69. doi: 10.1186/1472-6963-6-69. [PubMed: 16759386]. [PubMed Central: PMC1534028].
  • 14. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA. 2007;297(1):77-86. doi: 10.1001/jama.297.1.77. [PubMed: 17200478].
  • 15. Hendrich A. How to try this: Predicting patient falls. Using the Hendrich II Fall Risk Model in clinical practice. Am J Nurs. 2007;107(11):50-8. quiz 58-9. doi: 10.1097/01.NAJ.0000298062.27349.8e. [PubMed: 18075342].
  • 16. Rubenstein LZ. Falls in older people: Epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35 Suppl 2:ii37-41. doi: 10.1093/ageing/afl084. [PubMed: 16926202].
  • 17. Blalock SJ, Casteel C, Roth MT, Ferreri S, Demby KB, Shankar V. Impact of enhanced pharmacologic care on the prevention of falls: A randomized controlled trial. Am J Geriatr Pharmacother. 2010;8(5):428-40. doi: 10.1016/j.amjopharm.2010.09.002. [PubMed: 21335296].
  • 18. Chen KH, Chen LR, Su S. Applying root cause analysis to improve patient safety: Decreasing falls in postpartum women. Qual Saf Health Care. 2010;19(2):138-43. doi: 10.1136/qshc.2008.028787. [PubMed: 20351162].
  • 19. Dunlop DD, Manheim LM, Sohn MW, Liu X, Chang RW. Incidence of functional limitation in older adults: The impact of gender, race, and chronic conditions. Arch Phys Med Rehabil. 2002;83(7):964-71. doi: 10.1053/apmr.2002.32817. [PubMed: 12098157].
  • 20. Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: The maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59(3):383-9. doi: 10.1111/j.1532-5415.2011.03317.x. [PubMed: 21391928]. [PubMed Central: PMC3306056].
  • 21. Freeman R, Wieling W, Axelrod FB, Benditt DG, Benarroch E, Biaggioni I, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72. doi: 10.1007/s10286-011-0119-5. [PubMed: 21431947].
  • 22. Capone LJ, Albert NM, Bena JF, Tang AS. Predictors of a fall event in hospitalized patients with cancer. Oncol Nurs Forum. 2012;39(5):E407-15. doi: 10.1188/12.ONF.E407-E415. [PubMed: 22940520].
  • 23. Spoelstra SL, Given BA, Schutte DL, Sikorskii A, You M, Given CW. Do older adults with cancer fall more often? A comparative analysis of falls in those with and without cancer. Oncol Nurs Forum. 2013;40(2):E69-78. doi: 10.1188/13.ONF.E69-E78. [PubMed: 23448747].
  • 24. Kim EK, Lee JC, Eom MR. [Falls risk factors of inpatients]. J Korean Acad Nurs. 2008;38(5):676-84. Korean. doi: 10.4040/jkan.2008.38.5.676. [PubMed: 19114756].
  • 25. Blair E, Gruman C. Falls in an inpatient geriatric psychiatric population. J Am Psychiatr Nurses Assoc. 2016;11(6):351-4. doi: 10.1177/1078390305284659.
  • 26. Hignett S, Masud T. A review of environmental hazards associated with in-patient falls. Ergonomics. 2006;49(5-6):605-16. doi: 10.1080/00140130600568949. [PubMed: 16717012].
  • 27. Salgado RI, Lord SR, Ehrlich F, Janji N, Rahman A. Predictors of falling in elderly hospital patients. Arch Gerontol Geriatr. 2004;38(3):213-9. doi: 10.1016/j.archger.2003.10.002. [PubMed: 15066308].
  • 28. Perell KL, Nelson A, Goldman RL, Luther SL, Prieto-Lewis N, Rubenstein LZ. Fall risk assessment measures: An analytic review. J Gerontol A Biol Sci Med Sci. 2001;56(12):M761-6. doi: 10.1093/gerona/56.12.M761. [PubMed: 11723150].
  • 29. Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij SE. Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing. 2008;37(1):19-24. doi: 10.1093/ageing/afm169. [PubMed: 18194967].
  • 30. Shorr RI, Mion LC, Chandler AM, Rosenblatt LC, Lynch D, Kessler LA. Improving the capture of fall events in hospitals: Combining a service for evaluating inpatient falls with an incident report system. J Am Geriatr Soc. 2008;56(4):701-4. doi: 10.1111/j.1532-5415.2007.01605.x. [PubMed: 18205761]. [PubMed Central: PMC2361382].
  • 31. Khammarnia M, Ravangard R, Barfar E, Setoodehzadeh F. Medical errors and barriers to reporting in ten hospitals in Southern Iran. Malays J Med Sci. 2015;22(4):57-63. [PubMed: 28729811]. [PubMed Central: PMC5499771].
  • 32. Patino CM, McKean-Cowdin R, Azen SP, Allison JC, Choudhury F, Varma R, et al. Central and peripheral visual impairment and the risk of falls and falls with injury. Ophthalmology. 2010;117(2):199-206 e1. doi: 10.1016/j.ophtha.2009.06.063. [PubMed: 20031225]. [PubMed Central: PMC2819614].
  • 33. Rheaume J, Fruh S. Retrospective case reviews of adult inpatient falls in the acute care setting. Medsurg Nurs. 2015;24(5):318-24. [PubMed: 26665867].
  • 34. Najafpour Z, Jafary M, Saeedi M, Jeddian A, Adibi H. Effect size of contributory factors on adverse events: An analysis of RCA series in a teaching hospital. J Diabetes Metab Disord. 2015;15:27. doi: 10.1186/s40200-016-0249-3. [PubMed: 27471680]. [PubMed Central: PMC4964171].
  • 35. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: A review of the literature. Maturitas. 2013;75(1):51-61. doi: 10.1016/j.maturitas.2013.02.009. [PubMed: 23523272].
  • 36. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-94. doi: 10.1097/00001888-200402000-00019. [PubMed: 14744724].
  • 37. Rabol LI, Andersen ML, Ostergaard D, Bjorn B, Lilja B, Mogensen T. Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Qual Saf. 2011;20(3):268-74. doi: 10.1136/bmjqs.2010.040238. [PubMed: 21209139].
  • 38. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204(4):533-40. doi: 10.1016/j.jamcollsurg.2007.01.010. [PubMed: 17382211].
  • 39. Neutel CI, Perry S, Maxwell C. Medication use and risk of falls. Pharmacoepidemiol Drug Saf. 2002;11(2):97-104. doi: 10.1002/pds.686. [PubMed: 11998544].
  • 40. French DD, Campbell R, Spehar A, Cunningham F, Bulat T, Luther SL. Drugs and falls in community-dwelling older people: A national veterans study. Clin Ther. 2006;28(4):619-30. doi: 10.1016/j.clinthera.2006.04.011. [PubMed: 16750473].
Creative Commons License Except where otherwise noted, this work is licensed under Creative Commons Attribution Non Commercial 4.0 International License .

Search Relations:

Author(s):

Article(s):

Create Citiation Alert
via Google Reader

Readers' Comments