Using Root Cause Analysis to Inform a Falls Practice Change in the Home Care Setting

Root cause analysis and strategies for reducing falls among inpatients in healthcare facilities: A narrative review

Background and Aims

Root Cause Analysis (RCA) is a systematic process which can be applied to analyze fall incidences in reactive manner to identify contributing factors and propose actions for preventing future falls. To better understand cause of falls and effective interventions for their reduction we conducted a narrative review of RCA and Strategies for Reducing Falls among Inpatients in Healthcare Facilities.

Methods

In this narrative review, databases including Scopus, ISI Web of Science, Cochrane, and PubMed were searched to obtain the related literature published. Databases were searched from January 2005 until the end of March 2023. The Joanna Briggs Institute (JBI) tool was used for quality assessment of articles. To analyze the data, a five-stage framework analysis method was utilized.

Results

Seven articles that fulfilled the inclusion criteria were identified for this study. All of the selected studies were interventional in nature and employed the RCA method to ascertain the underlying causes of inpatient falls. The root causes discovered for falls involved patient-related factors (37.5%), environmental factors (25%), organizational and process factors (19.6%), staff and communication factors (17.9%). Strategies to reduce falls involved environmental measures and physical protection (29.4%), identifying, and displaying the causes of risk (23.5%), education and culturalization (21.6%), standard fall risk assessment tool (13.7%), and supervision and monitoring (11.8%).

Conclusion

the findings identify the root causes of falls in inpatient units and provide guidance for successful action plan execution. Additionally, it emphasizes the importance of considering the unique characteristics of healthcare organizations and adapting interventions accordingly for effectiveness in different settings.

Research and Practice in Quality Improvement and Implementation Science: The Synergy for Change Model

BACKGROUND

Nurses play an essential role in the achievement of quality depicted by the Quintuple Aim to improve clinical outcomes, patient experience, equity, provider well-being, and reduction of costs. When quality gaps occur, practice change is required and is facilitated by quality improvement (QI) and implementation science (IS) methods. QI and IS research are required to advance our understanding of the mechanisms that explain how evidence is implemented and improvements are made.

PROBLEM

Despite past efforts of the evidence-based practice and QI movements, challenges persist in sustaining practice improvements and translating research findings to direct patient care.

APPROACH

The purpose of this article is to describe the Synergy for Change Model that proposes that both QI and IS research and practice be used to accelerate improvements in health care quality.

CONCLUSIONS

Recognizing the synergy of QI and IS practice and research will accelerate nursing's contributions to high-quality and safe care.