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ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 1

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Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

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Root-Cause Analysis and Improvement Plan

Learner’s Name

Capella University

Improving Quality of Care and Patient Safety

Root-Cause Analysis and Improvement Plan

March, 2019

 

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 2

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

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 3

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.,

2014).

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 4

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

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 5

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

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 6

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.

Conclusion

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.

 

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 7

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

 

References

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.

http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8

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.

http://dx.doi.org/10.1111/jocn.13401

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.

https://doi.org/10.1177/1078390314553269

Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORN

Journal, 102(6), 617–628. https://doi-

org.library.capella.edu/10.1016/j.aorn.2015.10.006

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),

253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054

 

 

 

 

  • Root-Cause Analysis and Improvement Plan
    • Root-Cause Analysis of Falls in Geropsychiatric Inpatients
    • Application of Evidence-Based Strategies to Reduce Falls

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

 

 

 

 

 

 

 

 

Root-Cause Analysis and Improvement Plan

Learner’s Name

Capella University

Improving Quality of Care and Patient Safety

Root-Cause Analysis and Improvement Plan

March, 2019

 

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 2

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

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 3

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.,

2014).

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 4

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

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 5

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

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 6

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.

Conclusion

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.

 

 

 

ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 7

Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.

 

References

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.

http://dx.doi.org.library.capella.edu/10.1186/s13037-016-0107-8

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.

http://dx.doi.org/10.1111/jocn.13401

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.

https://doi.org/10.1177/1078390314553269

Serino, M. F. (2015). Quality and patient safety teams in the perioperative setting. AORN

Journal, 102(6), 617–628. https://doi-

org.library.capella.edu/10.1016/j.aorn.2015.10.006

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),

253–262. http://dx.doi.org/10.1097/NCQ.0000000000000054

 

 

 

 

  • Root-Cause Analysis and Improvement Plan
    • Root-Cause Analysis of Falls in Geropsychiatric Inpatients
    • Application of Evidence-Based Strategies to Reduce Falls

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