School of Nursing and Health Sciences

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
Root-Cause Analysis and Improvement Plan
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School of Nursing and Health Sciences, Capella University
NURS-FPX4020: Improving Quality of Care and Patient Safety
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Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
Root-Cause Analysis and Improvement Plan
According to Spath (2011), root-cause analysis is a methodical approach that aims to
discover the causes of adverse events and near misses for the purpose of identifying
preventive measures (as cited in Charles et al., 2016). A root-cause analysis of falls in
geropsychiatric patients was conducted at an inpatient mental health unit. The paper describes
and analyzes falls and discusses evidence-based strategies to reduce falls and determine a
safety improvement plan based on the utilization of existing organizational resources to
address these falls.
Root-Cause Analysis of Falls in Geropsychiatric Inpatients
According to Murphy, Xu, and Kochanek (2013), the Centers for Disease Control and
Prevention reported that falls were a leading cause of unintentional injury death in adults
aged 65 and above (as cited in Powell-Cope et al., 2014). Fall-related injuries that can lead to
serious head trauma are common among older adults. Injury falls are serious and could lead
to fractures, head injury, and intracranial bleed. According to the National Quality Forum
(2011), injury falls in older adults are almost always preventable (as cited in Powell-Cope et
al., 2014). Fall-related injuries prolong the stay of patients at the hospital and aggravate their
health conditions (Powell-Cope et al., 2014).
Considering the adverse implications of falls in such patients, a root-cause analysis
was conducted on the 20 cases of falls reported over a period of one year at a geropsychiatric
inpatient facility. The aim of the analysis was to understand the causes of falls in
geropsychiatric patients at the unit. The analysis was conducted by a team of five experts
including clinicians, supervisors, and quality improvement personnel. The cases reported had
been registered by a team of nurses who collated the data related to the falls. All the falls
were described as cases of slipping or tripping, and patients mostly sustained injuries
involving pain, mild swelling, and abrasions, with only two of the cases involving minor
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
fractures. It was also observed that all the falls occurred near the beds of patients and during
the evening or night shifts when nursing teams were more likely to be understaffed.
Geropsychiatric patients are known to be susceptible to falls under the influence of
drugs such as antidepressants and antipsychotics. Orthostatic hypotension (decrease in blood
pressure within three minutes of standing), ataxia (lack of voluntary muscular control caused
by injury to the central nervous system), and extrapyramidal slowing (impaired motor
functions) due to the use of drugs such as antidepressants, antipsychotics, sedatives,
hypnotics, alpha-blockers, and non-benzodiazepines are often found to be linked to these
kinds of falls (Powell-Cope et al., 2014). The team of experts reviewed the reports of falls
and noted that in over 50% of the cases, patients had been ambulating under the influence of
drugs. It was also noted that 80% of the patients who fell while ambulating under the
influence of drugs had been prescribed zolpidem.
At least 40% of the falls could be attributed to generalized weakness, disorientation,
and difficulty with mobility. Fall and injury risks are often complicated by behavioral
circumstances such as anger, anxiety, hyperarousal, and the inability to call for help or to
remember to call for help. Physical conditions that occur with substance abuse (such as
malnourishment and dehydration) co-exist with psychiatric disability and cause further
complications (Powell-Cope et al., 2014).
Another factor that plays a role in patient safety is infrastructure in hospitals. This was
particularly noteworthy as all the falls studied had occurred when patients ambulated near
their beds. The use of beds with adjustable height, bed- and chair-exit alarms, and nonskid
footwear are known to prevent fall-related injuries in psychiatric patients (Powell-Cope et al.,
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
Application of Evidence-Based Strategies to Reduce Falls
Considering that all the falls reported occurred near the patients’ beds, infrastructural
changes such as the installation of bed- and chair-exit alarms are recommended. Falls from
beds are common in patients with cognitive impairments. Installing electronic alarm systems
was found to be a feasible and effective fall prevention strategy in such cases (Wong Shee,
Phillips, Hill, & Dodd, 2014).
Strategies such as team engagement and proactive planning to avoid falls can be
implemented in inpatient geropsychiatric wards. Forming a quality and patient safety team
can serve as an essential safety net and drive a proactive approach rather than a reactive one
toward reducing sentinel events. Such a team could include existing staff in the unit that are
selected based on their skills and experience. The primary focus of the team would be to
identify, evaluate, measure, and improve processes and activities related to patient safety
within the unit (Serino, 2015).
Better management of medication must be implemented to reduce falls that occur
under the influence of drugs. Administering melatonin instead of zolpidem reduces the level
of sedation. Lower levels of sedation reduce the frequency of patients’ visits to the bathroom
at night as well as the aftereffects of sedatives in the morning (Powell-Cope et al., 2014).
Improvement Plan
The improvement plan involves a two-pronged approach: improving staff
effectiveness and coordination and implementing environmental modifications. The first part
of the plan focuses on increasing the effectiveness of patient monitoring and staff
coordination through intentional rounding, one-to-one observation of patients, and increased
communication among staff. Intentional rounding is a system wherein the nursing staff
conduct structured routine checks on patients at regular intervals. The duration of intervals is
decided based on the needs of patients in the unit. Intentional rounding is known to be
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
particularly effective in reducing falls (Morgan et al., 2016). One-to-one observation is
recommended for high-fall-risk patients. One-to-one observation of patients by moving them
close to the nurse’s station aids effective monitoring and reduces the risk of falls. Sentinel
events can be prevented by promoting interdisciplinary collaboration in health care. Good
communication and collaboration between physicians, therapists, kinesio therapists, and
occupational therapists are essential in monitoring patient activity (Powell-Cope et al., 2014).
The second part of the improvement plan focuses on environmental modifications to
existing infrastructure in the unit to reduce falls. Installing chair- and bed-exit alarms to alert
staff when a patient attempts to leave the chair or bed has proven to be effective in reducing
falls. These alarms can be attached to the patient directly or to the chair or bed the patient
uses (Wong Shee et al., 2014). Other recommended environmental modifications include
using creative display signage beside patients’ beds. This could be magnets next to the name
of a fall-risk patient on a white board or the sign of a leaf on a patient’s bedroom door. Such
displays alert staff and visitors of the risk involved with each patient. The use of nonslip
strips on floors (especially in bathrooms) and the installation of geriatric-friendly sanitary
ware such as handrails, assist bars, shower chairs, and raised toilet chairs enhance patient
safety (Powell-Cope et al., 2014). The attending staff in the unit would have to be trained to
facilitate and monitor the use of environmental modifications such as electronic alarms to
ensure their successful implementation.
It is crucial to identify and leverage existing organizational resources when
implementing the improvement plan. The first part of the improvement plan involves
utilizing the skills and expertise of existing staff members rather than hiring new members to
assist in fall prevention. To improve monitoring of patients, the staff members are trained on
intentional rounding techniques and one-to-one observation. The environmental interventions
suggested in the second part of the plan involve the installation of additional components to
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
existing hospital fixtures such as chairs, beds, doors, and floors. Leveraging existing
resources reduces the overall cost and effort involved in implementing the plan and ensures
minimal disruption to ongoing patient routines and staff-led fall-prevention practices within
the unit.
Falls are the leading cause of unintentional injury deaths in geropsychiatric patients
and are largely preventable. A root-cause analysis of falls in such patients was conducted at
an inpatient mental health unit. Infrastructural gaps and ambulation under the influence of
drugs were found to be primary factors that precipitated the falls reported in the unit. The
paper discusses evidence-based strategies such as medication management, installation of
electronic alarms, and formation of a quality and patient safety team that would help reduce
falls. A two-pronged improvement plan was formed to systematically reduce falls in the unit.
The plan involved improving staff effectiveness and coordination and implementing
environmental modifications.
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
Charles, R., Hood, B., Derosier, J. M., Gosbee, J. W., Li, Y., Caird, M. S., . . . Hake, M. E.
(2016). How to perform a root cause analysis for workup and future prevention of
medical errors: A review. Patient Safety in Surgery, 10.
Morgan, L., Flynn, L., Robertson, E., New, S., Forde‐Johnston, C., & McCulloch, P. (2016).
Intentional rounding: A staff‐led quality improvement intervention in the prevention
of patient falls. Journal of Clinical Nursing, 26(1-2), 115–124.
Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., …
Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mental
health units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339.
Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORN
Journal, 102(6), 617–628.
Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, and
effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with
cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3),

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