A Root Cause Analysis of a Fall

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Transcript of A Root Cause Analysis of a Fall

Page 1: A Root Cause Analysis of a Fall
Page 2: A Root Cause Analysis of a Fall

A fall story

• A 61 years-old man diagnosed with a diagnosis of small cell lung carcinoma suffered a fall during his stay at the hospital . A CAT scan showed a subdural hematoma located in the fox cerebri and right lateral ventricule.

• An analysis based in the Reason model and a summarized Root cause analysis is proposed.

Page 3: A Root Cause Analysis of a Fall

Fox cerebri

hematoma

Page 4: A Root Cause Analysis of a Fall

Hematoma

Fox cerebri and right ventricule

Page 5: A Root Cause Analysis of a Fall

Enoxaparine 40 mg/dayMorphine

and Pain-

Killers

Platelets:

76000Fall hitting the head

Page 6: A Root Cause Analysis of a Fall
Page 7: A Root Cause Analysis of a Fall
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RCA summarized

Patient with lung cancer, under prophylactic heparin (40 mg/day) and platelets 76000 suffered a fall during a walk

The use of psychotropic drugs, less nutrient and muscle atrophy were associated to the fall

A low platelets value, heparin and an strong head trauma were asociated with the intracranial bleeding.

Analysis and recommendations

Page 9: A Root Cause Analysis of a Fall

Fish Bone diagram

Fall.Hitting the head

No visual control

No “holding”railing

No asking For permission

“no medical event”?Nurses?

Lack of communication

STRUCTURE PROCESS FUNCTIONS

No alarm when psychotropics

Page 10: A Root Cause Analysis of a Fall

Analysis and Improvement proposals

• 1. An oncologic patient under psychotropic drugs, with muscular atrophy and a weak general situation is at high risk for a fall when he or she start to walk again.

• 2. This simple situation must be under control: the healthcare team must be informed when the patient is going to start walking. An auxilliary nurse must be attending. An orthopedic help must be considered to facilitate walking.

• 3. The combination of psychotropics, pain killer and heparin is a risky combination when the patient start walking .


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