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

Abstract

Background: Patients’ fall is considered as a challenge to patient safety, which entails not only prolonged hospital stays and higher costs, however, it may also result in injuries and even death. Objectives: This study aimed to identify attributed root causes and to develop preventive strategies. Methods: The present study is a multiphase qualitative study in which all fall incidents were studied deploying a root cause analysis process in accordance with the modified NPSA protocol in an educational hospital within a 9-month period. The contribution and association of risk factors attributed to each fall incident were analyzed using descriptive and analytical statistics. Finally, a nominal group technique was used, with specialist and holding three separate rounds, for determining preventive strategies of falling in health care facilities. Results: Out of a total of 110 fall incidents, 657 root causes were identified. Three groups of attributed causes, including patient, task, and education factors were found to have a greater share in the patient falling. Based on the identified root causes, fall prevention interventions were selected by members as specialized panels, who rated the solutions in several sessions. Ultimately, interventions agreed less than 70% were removed, and other potential preventive interventions were implemented in the form of a hospital-based trial. Conclusions: We found that a fall is the result of intrinsic and extrinsic risk factors. The first step in preventing falls is proper assessment of the patient in terms of clinical condition. Evaluation of the environment of the hospital is also essential to identify problems as well as developing amendment programs. Due to missing data on falls reported by nurses, it seems unwise to solely rely on the submitted reports.