In 2013 four district health boards (DHBs) provided their full internal analysis behind falls-related serious adverse events reported to the Commission during 1 July 2011–31 June 2012, for a review led by Sandy Blake RN, Clinical Lead for the Reducing Harm from Falls programme.

The falls events had been fully reviewed by DHB teams. Those internal reports were valuable for further analysis of key findings (including contributing factors) and recommendations. We would like to thank the DHBs for their willingness to support this project, and their commitment to reducing harm from falls.

The review findings are available in the report Learnings from in-patient falls: Analysis of a sample of reported serious adverse events 2011–12.

The main aim was to look for any themes amongst the causes and identify opportunities for improvement. The National Reportable Events Policy requires a formal review using RCA methodology of all SAC 1 and SAC 2 events, to understand what happened, why it happened and what can be done to stop the harm happening again.

Another aim was to assess the analysis process. The review identified that RCA methodology used was not used in every case and the quality of the reports provided varied widely.

Variations in method and lack of identified root causes and linkages between identified root causes and recommendations suggest there is room for improvement in the use of RCA methodology.

In many instances, a more detailed report from DHBs would have been useful. To address this, we proposed the following inter-related projects, which will better support investigation, analysis and the formulation of recommendations in relation to fall incidents.

  1. Consistency in the classification of harm related to falls. This will clarify:
    • the level of investigation and analysis required for each level of harm
    • which fall incidents are the serious harm events to be reported to the Commission (this is valuable sector wide
  1. A human factors guide and framework. This will guide critical thinking through use of the root cause analysis (RCA) methodology required for serious adverse events. It will also be useful for analysis of less serious fall events.
  2. A falls analysis template (based on the Human Factors Framework). Consideration will be given to linking the human factors framework information to the template for Reportable Events Brief Part B
  3. A framework for assessing the quality of analysis of events requiring RCA methodology.

Key people involved in the practical aspects of reporting and analysing of serious harm events have had critical input to the human factors guide and framework and the falls analysis template.

We expect ongoing feedback and improvement. If you would like more information please contact the Health Quality & Safety Commission.

Last updated 01/11/2018