ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN ESSAY
Running head: ROOT-CAUSE ANALYSIS AND IMPROVEMENT PLAN 1
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 minorROOT-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).
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