Analysing and learning from fall events

13 May 2014 | Reducing Harm from Falls

Root cause analysis methodology

In New Zealand, all hospital patient falls with serious harm require an individual indepth review using root cause analysis (RCA) methodology.[i] This methodology is based on a human factors approach which takes into account the relationship between human behaviour, system design and safety.

Some experts recommend using the RCA methodology across several incidents,[ii],[iii] either to aggregate the findings in a number of completed RCA investigations, or for a combined investigation of a cluster of falls (usually associated with less serious harm) in similar circumstances.[iv] These approaches both recommend actions based on the findings about common causes and contributing factors.

In a report on their experiences implementing a set of hospital-wide actions to prevent falls, Volz and Swaim (2013) say that the most effective strategy was the ‘Friday fall review’.[v] In this weekly meeting, managers or team leaders from every unit where there had been a patient fall presented their findings about the fall event to the wider group involved in falls prevention. Others involved in the fall event could be included. The style of the meeting was ‘collegial, non-threatening and educational’ and emphasised issues from system and process perspectives. Each fall was discussed indepth to determine the cause, contributing factors and what could have been done to prevent the fall.  From the themes identified, actions were planned and implemented. 

Have you got a story to share about how your team or organisation supports learning from falls to take actions which improve patient/resident/client safety?  Please be in touch with us at info@hqsc.govt.nz.

 


[i] Health Quality & Safety Commission. 2012. New Zealand Health and Disability Services – National Reportable Events Policy. Wellington: Health Quality & Safety Commission. URL: https://www.hqsc.govt.nz/publications-and-resources/publication/320/

[ii] Patient Safety First. 2009. The ‘How to’ Guide to Reducing Harm from Falls. London: National Patient Safety Agency.

[iii] Healey F, Scobie S. 2007. Slips, trips and falls in hospital. London: National Patient Safety Agency

[iv] National Patient Safety Agency. 2010. A Guide to Aggregated and Multi-Incident RCA Analysis. NHS National Patient Safety Agency. URL: http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60187&type=full&servicetype=Attachment

[v] Volz TM, Swaim TJ. 2013. Partnering to prevent falls: using a multimodal multidisciplinary team. Journal of Nursing Administration 43(6): 336-41.

Last updated 03/12/2021