Medical Errors: Root Cause Analysis




Falls in the Elderly Patients


New England Institute of Technology


Falls In Elderly Patients

Falls are a leading cause of disability and even death in older adults and when a fall occurs, it impacts on their independence. It is important to identify the risks associated with falling in the elderly, to be able to reduce the incidents of falls. The elderly population has an accelerated growth coupled with an increased prevalence of chronic degenerative diseases which oftentimes leads to a fall (Alvarez-Barbosa, 2016). Old age has a strong association with the risk of falls because of the biological, psychological and aging process which leads to structural and functional changes that accumulate gradually with increasing age. These changes decrease the performance of gross and motor skills, thereby causing weakness and encouraging them to fall (Alves, 2016). Another factor that contributes to falls in the elderly is the number and types of medications being given to them such as anti-anxiety medications, antidepressants, diuretics, hypnotics, and antipsychotic medications. Although the benefits outweigh the risks, these medications sometimes get them confused, drowsy and weak (Leland, 2012). Cognitive ability and mental health issues should be evaluated within the context of the individual patient's social situation by being alert to the occurrence of any change in mental function. Using an organized approach to the varied aspects of geriatric health, healthcare providers can improve the care that they provide for their older patients. Changes in mental status can have a profound impact on elderly patients and their families (Miller, 2000). Safety should be our topmost priority and we should create a safe environment for the patients. Some of the ways by which a safer environment can be created include decluttering their space, ensuring the hallways are free of any item, frequent monitoring of patient, prompt response to call light, raised toilet seats, grab bars, self-locking wheelchairs/ rolling seated walkers, footwear for preventing slipping and tripping, helmets, wheelchair-related safety, equipment (body pillows, pool noodles, etc.) (Zubkoff, 2016).


Analysis Question


Root Cause Analysis Findings

Root cause

Plan of Action


What was the intended process flow?

List the relevant process steps as defined by the policy, procedure, protocol, or guidelines in effect at the time of the event. You may need to include multiple processes.

Note : The process steps as they occurred in the event will be entered in the next question.

Examples of defined process steps may include, but are not limited to:

· Site verification protocol

· Instrument, sponge, sharps count procedures

· Patient identification protocol

· Assessment (pain, suicide risk, physical, and psychological) procedures

· Fall risk/fall prevention guidelines

Patient assessment, frequent vital signs and neurological checks, Placing bed in low position and call light within patient’s reach. Prompt response to call light. Effects of medication. Muscle weakness and confusion.




Were there any steps in the process that did not occur as intended?

Explain in detail any deviation from the intended processes listed in Analysis Item #1 above.





What human factors were relevant to the outcome?

Discuss staff-related human performance factors that contributed to the event.

Examples may include, but are not limited to:

· Boredom

· Failure to follow established policies/procedures

· Fatigue

· Inability to focus on task

· Inattentional blindness/ confirmation bias

· Personal problems

· Lack of complex critical thinking skills

· Rushing to complete task

· Substance abuse

· Trust


Rushing to complete tasks because the nurse-patient ratio is poor.




How did the equipment performance affect the outcome?

Consider all medical equipment and devices used in the course of patient care, including AED devices, crash carts, suction, oxygen, instruments, monitors, infusion equipment, etc. In your discussion, provide information on the following, as applicable:

· Descriptions of biomedical checks

· Availability and condition of equipment

· Descriptions of equipment with multiple or removable pieces

· Location of equipment and its accessibility to staff and patients

· Staff knowledge of or education on equipment, including applicable competencies

· Correct calibration, setting, operation of alarms, displays, and controls

Neurogical assessments performed at intervals: every five minutes , every fifteen minutes, then every one hour, every four hours and then once in 8 hours.

Crash carts usually examined every night to ensure it’s up to date, and it’s usually kept at the nurses’ station for easy access.

Vital signs equipment are usually kept in the hallways.




What controllable environmental factors directly affected this outcome?

What environmental factors within the organization’s control affected the outcome?

Examples may include, but are not limited to:

· Overhead paging that cannot be heard

· Safety or security risks

· Risks involving activities of visitors

· Lighting or space issues

The response to this question may be addressed more globally in Question #17.This response should be specific to this event.

Tight spaces in the room for maneuvering of assistive mobility devices.




What uncontrollable external factors influenced this outcome?

Identify any factors the organization cannot change that contributed to a breakdown in the internal process, for example natural disasters.

Structural design of the facility




Were there any other factors that directly influenced this outcome?

List any other factors not yet discussed.


What are the other areas in the organization where this could happen?

List all other areas in which the potential exists for similar circumstances. For example:

· Inpatient surgery/outpatient surgery

· Inpatient psychiatric care/outpatient psychiatric care

Identification of other areas within the organization that have the potential to impact patient safety in a similar manner. This information will help drive the scope of your action plan.

Sub-acute care unit


Was the staff properly qualified and currently competent for their responsibilities at the time of the event?

Include information on the following for all staff and providers involved in the event. Comment on the processes in place to ensure staff is competent and qualified. Examples may include but are not limited to:

· Orientation/training

· Competency assessment (What competencies do the staff have and how do you evaluate them?)

· Provider and/or staff scope of practice concerns

· Whether the provider was credentialed and privileged for the care and services he or she rendered

· The credentialing and privileging policy and procedures

· Provider and/or staff performance issues

Every employee went through orientation at employment, trained to deliver safe patient care, ensure good hygiene and also underwent competency tests to ascertain skills level.

Providers are board certified and licensed.




How did actual staffing compare with ideal levels?

Include ideal staffing ratios and actual staffing ratios along with unit census at the time of the event. Note any unusual circumstance that occurred at this time. What process is used to determine the care area’s staffing ratio, experience level and skill mix?

Staffing ratio has always been an issue. A nurse has an average of 22 patients and more, a lot of times.




What is the plan for dealing with staffing contingencies?

Include information on what the organization does during a staffing crisis, such as call-ins, bad weather or increased patient acuity.

Describe the organization’s use of alternative staffing. Examples may include, but are not limited to:

· Agency nurses

· Cross training

· Float pool

· Mandatory overtime

· PRN pool

During staffing crisis, on site staff are mandated to work overtime. Alternative staffing is mainly by PRN pool.


Were such contingencies a factor in this event?

If alternative staff were used, describe their orientation to the area, verification of competency and environmental familiarity.

No, PRN staff also get the same orientation full or part time staff get.




Did staff performance during the event meet expectations?

Describe whether staff performed as expected within or outside of the processes. To what extent was leadership aware of any performance deviations at the time? What proactive surveillance processes are in place for leadership to identify deviations from expected processes? Include omissions in critical thinking and/or performance variance(s) from defined policy, procedure, protocol and guidelines in effect at the time.

Staff performed as expected.




To what degree was all the necessary information available when needed? Accurate? Complete? Unambiguous?

Discuss whether patient assessments were completed, shared and accessed by members of the treatment team, to include providers, according to the organizational processes.

Identify the information systems used during patient care.

Discuss to what extent the available patient information (e.g. radiology studies, lab results or medical record) was clear and sufficient to provide an adequate summary of the patient’s condition, treatment and response to treatment.

Describe staff utilization and adequacy of policy, procedure, protocol and guidelines specific to the patient care provided.

Patient assessments were completed within the stipulated timeframe and accessible to all members of the healthcare team. The information was accurate and complete as we had templates of information sheets to guide us and it was shared through the company website, telephones, fax machines.




To what degree was the communication among participants adequate for this situation?

Analysis of factors related to communication should include evaluation of verbal, written, electronic communication or the lack thereof. Consider the following in your response, as appropriate:

· The timing of communication of key information

· Misunderstandings related to language/cultural barriers, abbreviations, terminology, etc.

· Proper completion of internal and external hand-off communication

· Involvement of patient, family and/or significant other

Anytime a patient falls, the supervising nurse is notified immediately, the physician is notified immediately too and the patient’s significant other. The SBAR technique is used to communicate with the doctors and supervisor.




Was this the appropriate physical environment for the processes being carried out for this situation?

Consider processes that proactively manage the patient care environment. This response may correlate to the response in question 6 on a more global scale.

What evaluation tool or method is in place to evaluate process needs and mitigate physical and patient care environmental risks?

How are these process needs addressed organization-wide?

Examples may include, but are not limited to:

· alarm audibility testing

· evaluation of egress points

· patient acuity level and setting of care managed across the continuum,

· preparation of medication outside of pharmacy

My facility uses only bed alarms for certain patients who are at high risk of falling. Confusion oftentimes lead to falls and frequent monitoring by staff helps avoid this. For example I try to prepare each patient’s medication at the entrance of their room so as to be able to watch them.




What systems are in place to identify environmental risks?

Identify environmental risk assessments.

· Does the current environment meet codes, specifications, regulations?

· Does staff know how to report environmental risks?

· Was there an environmental risk involved in the event that was not previously identified?

The facility has to meet certain requirements laid down by the state to ensure patient safety and how to report events. No new environmental risk was identified. And in the case of any new development staff knows to report to maintenance department.




What emergency and failure- mode responses have been planned and tested?

Describe variances in expected process due to an actual emergency or failure mode response in connection to the event.

Related to this event, what safety evaluations and drills have been conducted and at what frequency (e.g. mock code blue, rapid response, behavioral emergencies, patient abduction or patient elopement)?

Emergency responses may include, but are not limited to:

· Fire

· External disaster

· Mass casualty

· Medical emergency

Failure mode responses may include, but are not limited to:

· Computer down time

· Diversion planning

· Facility construction

· Power loss

· Utility issues

Quarterly fire drills are performed. Safety/ emergency in services are conducted monthly to teach and remind staff how to respond in case of emergencies.




How does the organization’s culture support risk reduction?

How does the overall culture encourage change, suggestions and warnings from staff regarding risky situations or problematic areas?

· How does leadership demonstrate the organization’s culture and safety values?

· How does the organization measure culture and safety?

· How does leadership establish methods to identify areas of risk or access employee suggestions for change?

· How are changes implemented?

The overall culture or management/staff culture welcomes suggestions from staff members regarding patient care and safety. Safety and other changes are measured by questionnaire results.




What are the barriers to communication of potential risk factors?

Describe specific barriers to effective communication among caregivers that have been identified by the organization. For example, residual intimidation or reluctance to report co-worker activity.

Identify the measures being taken to break down barriers (e.g. use of SBAR). If there are no barriers to communication discuss how this is known.

I have not noticed any barriers to communication. This may be due to the fact that there is a guideline, a form to fill, a recognized protocol for every incident or event.




How is the prevention of adverse outcomes communicated as a high priority?

Describe the organization’s adverse outcome procedures and how leadership plays a role within those procedures.

Through delivery of regular in service trainings




How can orientation and in-service training be revised to reduce the risk of such events in the future?

Describe how orientation and ongoing education needs of the staff are evaluated and discuss its relevance to event. (e.g. competencies, critical thinking skills, use of simulation labs, evidence based practice, etc.)

By constantly reevaluating the contents of each in service training to ensure it meets the current learning needs of the staff, frequent competency tests, research and application of evidence based practices




Was available technology used as intended?

Examples may include, but are not limited to:

· CT scanning equipment

· Electronic charting

· Medication delivery system

· Tele-radiology services

My facility does partly electronic charting, partly paper charting. Electronic vital signs equipment are also used.




How might technology be introduced or redesigned to reduce risk in the future?

Describe any future plans for implementation or redesign. Describe the ideal technology system that can help mitigate potential adverse events in the future.

Complete or full electronic charting which will centralize more patient information for easier access to providers and other healthcare team members.



Action Plan

Organization Plan of Action

Risk Reduction Strategies


Responsible Party

Method: Policy, Education, Audit, Observation & Implementation

For each of the findings identified in the analysis as needing an action, indicate the planned action expected, implementation date and associated measure of effectiveness. OR. …

Action Item #1:

Prompt response to call light. Effects of medication. Muscle weakness and confusion.



If after consideration of such a finding, a decision is made not to implement an associated risk reduction strategy, indicate the rationale for not taking action at this time.

Action Item #2:


Rushing to complete tasks because the nurse-patient ratio is high

Check to be sure that the selected measure will provide data that will permit assessment of the effectiveness of the action.

Action Item #3:

Tight spaces in the room for maneuvering of assistive mobility devices.

Consider whether pilot testing of a planned improvement should be conducted.

Action Item #4:

Staffing ratio has always been an issue. A nurse has an average of 22 patients and more, a lot of times.

Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Identify where the improvements will be implemented.

Action Item #5:

Revision of orientation and in service training

Action Item #6:

Action Item #7:

Action Item #8:


Álvarez-Barbosa, F., Pozo-Cruz, B., Pozo-Cruz, J., Alfonso, R., Sañudo-Corrales, B., Rogers, E. (2016). Factors Associated with the Risk of Falls of Nursing Home Residents Aged 80 or Older. Rehabilitation nursing. 41(1): 16-25. Database: CINAHL Complete

Alves, A., Freire de Araújo Patrício, A., Fernandes de Albuquerque, K., Duarte, M., Jiovana de Souza, S., Salles de Oliveira, M. (2016). Occurrence of falls among elderly institutionalized: prevalence, causes and consequences. Journal of Research& Fundamental care online. 4376-4386.

Leland, N., Gozalo, P., Teno, J., Mor, V. (2012). Falls in newly admitted nursing home residents: A National study. Journal of the American Geriatrics Society. 60(5): 939-945. Database: Academic Search Complete.

Miller, K., Zylstra, R., Standridge, J. (2000). The Geriatric patient: A Systematic approach to maintaining health. American Family Physician. 61(4):1089-1104.

Zubkoff, L., Neily, J., Quigley, P., Soncrant, C., Yinong, Y., Boar, S., Mills, P. (2016). Virtual breakthrough series, Part 2: Improving fall prevention practices in the Veterans Health Administration. Joint Commission Journal on Quality & Patient Safety. 42(11): 497-500.