Use of Root Cause Analysis to Prevent Falls and Promote Patient Safety in Clinical Rehabilitation

Objective: To apply Root Cause Analysis to explore the causes of patient falls and determine the implement procedures to prevent them.

Design: Root Cause Analysis was conducted retrospectively using comprehensive error review to discover and correct the causes of errors.

Setting: Physical medicine and rehabilitation department in a medical center in Taiwan. Interventions: We used causal trees to clarify possible reasons for patient falls, including the patients’ personal characteristics, factors pertaining to the interactions among the medical team, the team’s workload and level of training, and the quality of communication between medical staff and the patient. In advance, Root Cause Analysis was analyzed by using reactive barriers for each factor.

Main outcome measures: Incidence and complications of patient falls before and after Root Cause Analysis.

Results: No patient falls occurred during the first 6 months after implementing the measures identified in the analysis. Two falls occurred after 6 months, but the patients were both assisted promptly and suffered no injuries. The annual incidence of falls decreased from 4.8 per 100,000 subjects to 1.9 and 0.9 in the next two years of follow up, respectively.

Conclusion: The application of root cause analysis in the setting of clinical rehabilitation did not completely prevent falls. However, the incidence and complication of falls were reduced. Therefore, it is worthwhile to promote application of Root Cause Analysis to clinical rehabilitation treatment to enhance the quality of patient safety in the future.