MHA 505 Root-Cause Analysis and Safety Improvement Plan Root-Cause Analysis Paper

Root cause analysis is a process through which causes of adverse events and other issues that almost occur are analyzed so that preventive measures or improvements can be made (Spath, 2011). This paper provides and root cause analysis and improvement plan for the patient safety and reduction in falls for geriatric patients in inpatient geriatric units. Moreover, the paper provides evidence-based strategies that aim to improve the safety of the geriatric patients through reduction of falls. The evidence based strategies are used to determine a safety improvement plan depending on existing resources. The RCA is provided for a geriatric unit in a county medical center facility. The geriatric unit for the medical center is made up of a 100 bed ward.

MHA 505 Root-Cause Analysis and Safety Improvement Plan Root-Cause Analysis Paper

Analysis of the Root Cause: Safety of Geriatric Patents Concerning Falls in Inpatient Geriatric Units

Patient safety entails protection of the patient from issues such as injuries during health care (Cameron et al. 2018). Patient falls are thus ranked amongst the prevalent patient safety issue in hospitals, especially geriatric units. The geriatric unit experiences many falls and is amongst the leading causes of injury deaths in the older patients. With an expected increase in the aging population, it is also likely that the number of elderly patients rises. The patient falls in the geriatric units are often witnessed, and they are referred to medical errors that need to be addressed since is it a safety issue. Such medical errors as falls occur due to issues such as environmental errors, lack of interprofessional teamwork, and ineffective communication between patients and the caregivers (Cameron et al., 2018). The root cause analysis (RCA) is used in the review of falls in a geriatric unit at a medical center.

The RCA is conducted for the geriatric unit that reported 30 falls the previous year and has been averaging over 30 falls annually since 2010. The primary objective of the RCA is to establish what leads to the falls amongst the patients within the unit and provide a possible solution to deal with the falls. The RCA analysis was the role of an interprofessional team, including one supervisor, two nurses, one clinician, and a quality improvement officer. The 30 reported cases are reported by the nurses, and they are often recorded and found in the geriatric unit’s electrical records with 2 of the cases being fatal as it led to the death of the patients due to concussions. Other results of the falls were injuries, including body swellings, fractures, pain, and abrasions. Most of the reported cases were associated with tripping and slipping and mostly in or near the patients’ beds. Moreover, most of the falls were reported during the evenings, early mornings, and at nights when the nurses were understaffed or when there were changing their shifts.

Various factors subject the geriatric patients to falls, for example, being under the influence of medication, for example, antidepressants and most of them also have cognitive psychology issues that make them forget things. As they wander within the units, they are subjected to environmental risk factors that can cause the falls. The use of medicine leads the geriatric patients to lack voluntary muscle control (ataxia), impaired cognitive or motor functions (extrapyramidal slowing), and decrease in blood pressure within few minutes of continuous standing (orthostatic hypertension) (Phelan et al., 2014). These issues subject the patients to risks of falls as they can just collapse or slip. Some of the drugs that have been associated to these falls include sedatives, antipsychotics, antidepressants, hypnotics, non-benzodiazepines, and alpha- blockers (Phelan et al., 2014).

According to the experts that reviewed the reported cases at the geriatric unit, about 65% of the falls were associated with patients being under drug influence as the falls took place within ten minutes of the drugs being administered. The other 35% are associated with general body weaknesses in the geriatric patients, cognition impairment, and partial blindness that leads to mobility difficulties, thus the falls. Most of the patients from the reported ones that fell were in treatment for cardiovascular and neurodegenerative related diseases. The geriatric unit environment was also attributed as one of the main factors that lead to falls as the beds are not designed to hold the patients in their beds, the glass doors confuse the elderly patients with most having cognition and visual impairment issues, poor lighting, and the footwear was risky on the tilled floors since liquid leakages are regular in the unit.

Improvement Plan with Evidence-Based and Best-Practice Strategies

According to Spruce (2015), evidence based research in nursing leads to the establishment of the best interventions to improve quality of care. Preventive and improvement strategies are required to help in the reduction of the falls in the geriatric unit. The improvement plan focuses on two aspects, including improving the quality of healthcare services by the staff and the creation of an environment at the geriatric unit with minimal risk factors.

The first part of the plan focuses on quality care to improve the general safety of the patient. Since most of the falls were attributed to the medication issues, patient monitoring needs to be improved to reduce the effects that drugs have on these patients. To aid in this process, several aspects are required including physical therapy and exercise programs, minimizing and withdrawal of psychoactive medications, increasing nurse staffing during night shifts and effective communication amongst staff. Physical therapy or exercise programs must be started on the patients to ensure that there is improvement of strength, balance, and gait (Ambutas et al., 2017).

As identified earlier, some of the main issues associated with falls are the general body weaknesses amongst the patients. Therefore, physical therapy would go a long way in improving the general body weakness through improving the body strengths and balance of the patients (Lee et al., 2013 MHA 505 Root-Cause Analysis and Safety Improvement Plan Root-Cause Analysis Paper). All the patients in the geriatric unit would be required to undergo physical therapy. Another issue in the first part of the plan is to reduce, withdraw, or find alternatives for the psychoactive drugs (Lee et al., 2013). 65% of the falls were attributed to drug influence and thus reducing the use of the identified drugs, withdrawing them all together in situations that they are not required, and finding less influential alternatives can lead to minimizing the falls.

Another aspect in this part of the plan is to increase the staff nursing during the night shift to improve the monitoring of these patients as more nurses will be doing rounds in the unit and apart from the video monitoring physical monitoring where the nurses go to the patients’ bed at regular intervals would help in reducing the falls. The nurses would also undergo communication training to improve effective communication between themselves and between them and the patients (Cameron et al., 2018).

The second part of the improvement plan focuses on the geriatric unit environment. One of the main issues proposed is the changes in footwear and management of footwear by the hospital. The experts proposed that patients be provided with footwear that has grip even on the hospital’s slippery tiled floors. Another environmental proposal is the improvement of lighting by ensuring that there are enough light sources both at night and during the day and this ensures that patients can see well and know where there are obstacles (Lee et al., 2013). This aspect will help mainly the patients that have problems with their eyesight due to old age.

The glass doors will be replaced with wooden or plastic doors with bright colors, and this will enable the patients to see the doors and avoid collision as one of the issues that cause the falls. Finally, the beds will be fitted with protective boards, and electric alarms that would warn the nurses in case a patient needs anything (Shorr et al., 2012) Training of the staff and patients on the use of the electric alarms would be however essential to ensure that it is effective in reducing the falls.

Existing Organizational Resources

The improvement plan would require the use of existing organizational resources in its implementation process. The plan would require human resources and their skills and expertise, and this would include more nurses being deployed for the night shit hours. The existing staff would be trained on the specific additions such as the provision of physical therapy and the use of electric alarms. The environmental improvement part of the plan would require leveraging the existing capital in the medical center since it requires the installation of additional components such as lighting, buying of footwear, electric alarms, and the replacing of the doors. Mills (2016) states that leveraging of the existing human and capital resources ensure that the medical center would reduce the overall costs. Moreover, leveraging of existing resources ensures that the disruption in service provision within the geriatric unit is minimally affected.

MHA 505 Root-Cause Analysis and Safety Improvement Plan Root-Cause Analysis Paper References

  • Ambutas, S., Lamb, K. V., & Quigley, P. (2017). Fall reduction and injury prevention toolkit: Implementation on two medical-surgical units. Medsurg Nursing, 26(3), 175– 179, 197.
  • Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. The Cochrane database of systematic reviews, 9(9), CD005465.
  • Lee, A., Lee, K. W., & Khang, P. (2013). Preventing falls in the geriatric population. The Permanente Journal, 17(4), 37–39.
  • Phelan, E. A., Mahoney, J. E., Voit, J. C., & Stevens, J. A. (2015). Assessment and management of fall risk in primary care settings. The Medical clinics of North America, 99(2), 281– 293.
  • Mills, E. (2016). The WakeWings journey: Creating a patient safety program. AORN Journal, 103(6), 636–639.
  • Shorr, R. I., Chandler, A. M., Mion, L. C., Waters, T. M., Liu, M., Daniels, M. J., Kessler, L. A., & Miller, S. T. (2012). Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster-randomized trial. Annals of internal medicine, 157(10), 692–699.            00005
  • Spath, P. L. (2011). Error Reduction in Healthcare: A Systems Approach in Improving Patient Safety (2nd ed.). San Francisco: Jossey-Bass.
  • Spruce, L. (2015). Back to basics: Implementing evidence-based practice. AORN Journal: The Official Voice of Perioperative Nursing, 101(1), 106–114.