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General Hospital Psychiatry 34 (2012) 304–311

Using root cause analysis to reduce falls with injury in the psychiatric unitAlexandra Lee, M.S.a,⁎, Peter D. Mills, Ph.D., M.S.b, c, Bradley V. Watts, M.D., M.P.H.b,c

aVeterans Affairs National Center for Patient Safety Patient Safety Fellowship, White River Junction VA Medical Center, White River Junction, VT 05009, USAbVA National Center for Patient Safety Field Office, White River Junction, VT 05009, USA

cDartmouth Medical School, Hanover, NH 03755, USA

Received 20 September 2011; accepted 15 December 2011

Abstract

Objective: The objective was to identify how falls on psychiatric units occur, the underlying root causes and effective action plans to reducefalls and injuries.Methods: A search of theVeteransHealthAdministrationNational Center for Patient Safety databasewas conducted to identify root cause analysis(RCA) reviews where a fall was sustained by a patient on a psychiatric unit. Seventy-five RCAs from January 2000 toMarch 2010 were included.Results: One hundred and thirty-eight actions were identified from the RCA reports. The most common activities the individual was engagedin during a fall included getting up from a bed, chair or wheelchair (21.3%); walking/running (10.7%); bathroom related (9.9%) or behaviorrelated (9.9%). The most common root causes were environmental hazards (11.2%), poor communication of fall risk (8.9%), lack of suitableequipment (8.9%) and need for improvement of the current system for falls assessment (8.9%). Staff education (19.9%), development of toolsto improve falls documentation (17.0%) and providing falls prevention equipment (14.2%) were the most frequent actions taken.Conclusions: The results describe the location, activity and root causes surrounding falls that occur in psychiatric units resulting in injury,and provide some suggestions on how to implement a successful action plan.Published by Elsevier Inc.

1. Introduction

Falls that occur in the inpatient setting lead to physicalinjury 30% of the time, which results in an increased lengthof hospital stay and hospitalization costs [1]. Moreover, thecost of fall-related injuries is high. In 2000, the directmedical costs for nonfatal fall injuries in the United Statestotaled $19 billion [2]. By 2020, the cost of fall injuries forindividuals 65 years of age and above is expected to reach$43.8 billion [3]. There are also indirect costs associated witha fall including the loss of activities, fear of falling andpossible admittance to a rehabilitation or nursing facility.

The National Database of Nursing Quality Indicators hasreported that the rate of falls among hospitalized patients is 3to 4 per 1000 inpatient days of care [4]. The incidence of fallsoccurring in psychiatric units is even greater, with ratesestimated at 13.1 to 25 per 1000 inpatient days [4].

⁎ Corresponding author.E-mail addresses: alexandra.lee@va.gov (A. Lee), peter.mills@va.gov

(P.D. Mills).

0163-8343/$ – see front matter. Published by Elsevier Inc.doi:10.1016/j.genhosppsych.2011.12.007

Additionally, elderly patients on psychiatric units may bethe highest-risk group among all inpatients to sustain a hipfracture due to a fall [5]. There are many variables that maycontribute to the increased rate of falls on psychiatric units,such as patients' medical conditions. For example, a patientthat is confused or agitated may exhibit combative behavior.Depressed patients may have suppressed movements result-ing in changes to their gait, and manic patients may move tooquickly, increasing their risk of falling [6].

Many studies have also found a relationship betweenfalling and psychiatric medications that psychiatric patientsare frequently taking. Investigators have found that hyp-notics, antipsychotics, antidepressants, cardiovascularagents, diuretics and benzodiazepines may predisposepatients to falls [7–10]; they contribute to falls throughvarious mechanisms including increased drowsiness, confu-sion and balance problems [11]. In addition, Bloch andcolleagues determined that the use of antipsychotic drugsincreased the chance of falling by 78% [12].

Much of the current published falls research has focusedon risk factors for older adults and fall prevention

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interventions that have been valuable in the medical unitsetting. However, literature that discusses effective in-terventions to prevent falls on mental health units is limited.Blair and Gruman concluded that most falls among patientsover 60 years on a mental health inpatient unit occurredwhile the patient was ambulating or getting in/out of a chairor bed, or were toileting related [4]. Yates and colleaguesfound that revising inpatient falls programs resulted in a 32%decrease in psychiatric inpatient falls as well as a decrease inthe rate of injuries [13]. Some of the interventions applicableto psychiatric patients included use of nonskid gripper socks,altering or updating the high-fall-risk signage, staff educa-tion and providing sitters or other staffing for high-fall-riskpatients. Activity aprons which have features such aszippers, buttons and ribbons allow dementia patients toremain occupied with familiar actions and may also be anapplicable intervention for fall prevention [14].

To date, no study has reviewed large numbers of seriousfalls on psychiatric units to determine the system-levelcauses and interventions. The Veterans Health Affairs(VHA) National Center for Patient Safety (NCPS) databasecontains detailed reports of adverse events occurring inVeterans Affairs (VA) hospitals since 1999. The objective ofthis descriptive study was to use this database to identify howfalls occur, the underlying root causes for the falls andeffective action plans to reduce falls and injuries.

2. Methods

2.1. The VA NCPS Root Cause Analysis (RCA) program

The RCA framework was initially used in high-reliabilityindustries to identify the factors that underlie variation inperformance [15]. The framework was introduced to themedical community in the mid-1990s [15–17]. In medicine,RCA is a systematic process to retrospectively analyzeadverse events. The process seeks to answer three majorquestions: what happened, why did it happen and what canbe done to prevent it from happening again [15,16]? RCAs

Decision to doan RCA

(based onSAC, etc.)

Charter/Appoint team

Establishsequence

events

Identify cause

contribufactor

Identify correctiveactions that were

instituted in the pastdue to a similar event

Develop anaction plan

Identify whatwas learned and

educaterelevant parties

Develop indicators tomeasure outcomes

once an action plan isimplemented

Final RCaction siby institleaders

Fig. 1. RCA Team Process, adapted

are typically done in cases of death or serious injury topatients or in situations where such events were narrowlyavoided [18]. In 1996, the Joint Commission required allhospitals in the United States to conduct an RCA for someserious adverse events (so-called sentinel events) [19]. TheVA established the NCPS in late 1998 in an effort to improvepatient safety. By the end of August 2000, NCPS hadnationally implemented the use of RCA within the VA [16].Currently, many state departments of health, private-sectorhospitals and health systems around the world have safetyprograms that employ RCA to improve patient safety [18].

NCPS developed a system for performing an RCA toguide caregivers at the frontline [20]. Fig. 1 diagrams theRCA team process [21]. This system includes a computer-aided tool and a flipbook containing a series of six “triage”questions to help teams identify where the system can beimproved. A team is chartered to establish the sequence ofevents leading to the adverse event, conduct fact finding andsynthesize the information acquired using the tools andresources available. Once a final sequence of events isdetermined, the team identifies root causes and contributingfactors. Action plans are then developed to address thesecauses, and a measurement system is put in place to monitorthe implementation and effectiveness of the actions [22].RCA reports come into the VA NCPS via a securecomputerized reporting system where they are categorizedusing the NCPS Primary Analysis and Classification Systemand available for review by NCPS staff [23].

2.2. Review of RCA reports of falls occurring in psychiatricunits among veterans

In order to identify all RCA reports of falls on psychiatryunits, we searched the VHA NCPS database betweenJanuary 1999 (known date of the first RCA) and March2010 and collected all RCA reports with “Fall” listed as theevent in the incident field and “Psychiatry Area” in thelocation field. We then manually reviewed each case toensure that the fall occurred on a psychiatry unit in VA.

ofIdentify gaps in

information

Conduct fact finding:Interview, chart

reviews, andliterature reviews

Synthesizeinformation

acquired, may use“triage questions”

Establish finalversion of

sequence ofevents

root/tings

A andgn-offutionhip

RCA team advisorconducts follow-up

from VHA Handbook 1050.01.

Fig. 2. Specified primary activity of patient before or during fall, n=90.

306 A. Lee et al. / General Hospital Psychiatry 34 (2012) 304–311

Cases were coded based on the primary activity of thepatient before/during the fall, root causes and contributingfactors, action items, outcome measures and effectiveness ofeach action. The root causes and contributing factors wereclassified using a predefined rubric developed by the NCPS.There are five main categories including (1) Communication,(2) Environment/equipment, (3) Training, (4) Rules/policie-s/procedures and (5) Fatigue/scheduling problems [24]. Wealso added two categories, patient characteristics and facilitycharacteristics, to include all root causes addressed in theRCA reviews.

2.3. Measures of effectiveness

As part of the RCA process, teams develop measures foreach action item to determine if the implemented actionsresult in a positive change. We used Donabedian'sframework for assessing quality of care and classified themeasures into three main categories including structure,process and outcome indicators [25]. Structural indicatorsare characteristics of the setting where care occurs and thesystem's ability to provide for the health needs of theindividual or the community. Examples of structural changesmay include the development of a written policy andcompletion of staff training. Process indicators assess whatwas actually done in delivering care [26]. An example wouldbe if the measure indicated that all admitted patients wereassessed for orthostatic hypotension and documented in thepatient's medical record. Outcome indicators seek tomeasure the effects of care on the health status of patients.Examples of outcome indicators include the reduction offalls or fall-related injuries for patients. Outcome indicatorsare the most valid measure for determining whether an actionyielded a positive change in the care of a patient. In order forprocess and structural indicators to be valid, they must belinked to better outcomes or at least demonstrate an increasedlikelihood of improved outcomes [25–27].

Once actions are developed, implemented and measured,the individual responsible for implementation reports back tothe facility's patient safety manager on the effectiveness ofthe action. Then, the patient safety manager finalizes theRCA report and records the effectiveness of the measure as“worse,” “same,” “better,” “much better,” “not measured,”“not reported” or “not implemented.”

2.4. Effective action plans

In order for an action plan to be determined effective in ouranalysis, it had to fit two criteria: the outcome associated withthe action plan reported on the final RCA document musthave resulted in a “better” or “much better” outcome (asreported by the patient safety manager), and the outcomemeasure itself must have been either a process or outcomeindicator. We decided to exclude structural indicators fromour analysis because improvements in structure, e.g., whetheror not a policy was written or a training took place, do notclearly translate into a reduction of falls or fall-related injuries

for patients. Process and outcome indicators, on the otherhand, show that changes have been made toward the care forpatients, such as a change in how assessments are performedor a reduction in the overall rate of psychiatric unit falls, sothere is a higher chance of actual improvement in patient care.Action items were coded as related to education, proceduralchanges at the bedside, standardization or changes to staffing.Two independent researchers (A.L., B.W.) coded the RCAs.The first 10 cases were independently coded, resulting in a98.0% agreement (Kappa=0.98), and all discrepancies werediscussed and coded by consensus. The remaining cases wereindependently coded.

3. Results

Initially, 76 RCAs were identified. Of these, one case wasexcluded because the fall event did not occur in a psychiatricunit. There were 75 RCA reports between January 2000 andMarch 2010 that were included in the final analysis. TheseRCAs uncovered 179 root causes resulting in 138 actions toaddress the root causes.

3.1. Primary activity related to patient's fall

Fig. 2 displays the primary activities of the patient beforeor during a fall. In 21.1% (n=19) of the reported cases, theprimary activity that led to the fall was not documented in theRCA. Of the identified activities leading to fall, the mostfrequent activities included getting up from the bed or chair(21.1%, n=28), walking/running (19.7%, n=14) and usingthe bathroom (18.3%, n=13).

3.2. Root causes

The root causes discovered for falls and fall-relatedinjuries involved problems with rules, policies and pro-cedures (27.9%), environment and/or equipment (24.6%),communication (19.6%), patient characteristics (8.9%),training (8.4%), fatigue/scheduling problems (8.4%) and

Table 1Root causes of falls occurring in psychiatric units

Category Examples % of total (n)

Rules, policies and procedures 27.9% (50)Current system forfalls assessment/reassessmentneeds improvement

• Current assessment tool is insufficient for identifying patients at high falls risk 8.9% (16)• Nursing fall risk assessment is interpreted differently by staff• Morse Fall Risk Assessment was incorrectly scored

Management of medicationsneeds improvement

• No means by which ward staff could discuss medication needs with other psychiatristsresponsible for the patient

6.7% (12)

• Patient was inadequately medicated for the control of agitation• Patient was taking multiple medications which may have contributed to orthostatic hypotension• Lack of completion of medication risk assessment by provider on admission

Lack of a specific interventionfor a particular patient orpatient population

• Detoxification protocol was not followed, and there was no alcohol withdrawal assessmentform present for the patient

6.1% (11)

• Lack of clearly defined criteria for transferring patients may have led to fall riskstatus not being communicated• Interrupted monitoring of Coumadin on the mental health unit of a fall risk patient

Current system for falls interventionneeds improvement

• Inconsistent use of existing fall management technology 3.4% (6)• Patient's needs were not accurately identified prior to admission, which contributed tothe lack of proper fall prevention equipment being provided• Lack of individualized care planning for patients at high risk to fall

Falls assessment/reassessmentis not being done

• Fall risk assessment and precautionary measures were not addressed after a changein patient condition

1.1% (2)

Lack of current systemfor falls intervention

• Lack of a process to assess fall risk and implement prevention interventions uponadmission to the mental health unit

0.6% (1)

Falls intervention is not being done • Lack of implementation of a high fall risk treatment plan 0.6% (1)Environment/equipment 24.6% (44)Environment needs improvement • Physical layout of the unit increases ambulation distance for the patient 11.2% (20)

• Delay in repair of a missing floor tile• The path to the bathroom in the patient's room was poorly lit; therefore, a tripping hazardwould not be seen

Lack/inappropriate use of equipment • Lack of the use of fall prevention interventions, such as bed alarms andbathroom assistive devices

8.9% (16)

• Lack of the use of injury-minimizing/prevention interventions, such as anursing call light system, hip protectors and bedside mats• Scarce supply of geriatric chairs limited the placement options of the patient• Use of a standard wheelchair by unsteady patients as an ambulatory aid

Treatment area or milieu problems • Activities are not available to patients to occupy them during free time 4.5% (8)• Mixing dementia psychiatric patients with acutely psychotic patients on alocked unit increased the probability of patient injury

Communication 19.6% (35)Verbal communication of fallrisk needs improvement

• Patient's orthostasis was not communicated to higher-level practitioners 8.9% (16)• Veteran's assaultive behavior was not communicated between staff at the change of shift• Lack of communication regarding falls may have delayed or prevented assessment,evaluation and implementation of appropriate interventions

Documentation needs improvement • No documentation by physician for tapering or discontinuing medications contributedto increased fall risk

8.4% (15)

• Inconsistent documentation practices of providers that do not explain medication changes• Absence of clear documentation of the fall prevention interventions in place for the patient

Medical record (physical andelectronic tools) needs improvement

• Dual medical record system, including electronic and paper records, bothheld incomplete information

2.2% (4)

• No system for clearly recording outpatient medications in electronic medical recordPatient characteristics 8.9% (16)Medical issues • Patients with dementia have compromised cognitive functioning and often aggressive behaviors 8.4% (15)

• Patient's age, balance problems and other comorbidities lead to an increased risk of falling• Due to the patient's diagnosis of schizophrenia and an extensive history of violent behavior,there was a likelihood that the patient would become unpredictably uncontrollable and at highrisk for self-endangerment and endangering staff

Patient culture • The unwillingness and/or cognitive impairment of high-fall-risk patients towear hip protector garments

0.6% (1)

Need for staff education • No training for prevention and management of aggressive behavior in patientswas provided to staff members

8.4% (15)

• Staff unaware of the process to transfer patients• Staff do not know how to use the Morse Fall Risk Assessment tool

(continued on next page)

307A. Lee et al. / General Hospital Psychiatry 34 (2012) 304–311

Table 1 (continued)

Category Examples % of total (n)

Fatigue/scheduling problems • Inadequate staff to monitor the level and intensity of patients on the unit 8.4% (15)• Due to time constraints, staff incompletely reviewed patient's transfer records and didnot identify that the patient was at a fall risk

Facility characteristics • No facility in the area is readily available to manage psychiatric patients whodisplay behavioral difficulties

2.2% (4)

• Facility has a culture of not reporting errors and near misses• Nursing culture is such that, during night hours, the medical officer of the day isonly contacted in emergent situations

308 A. Lee et al. / General Hospital Psychiatry 34 (2012) 304–311

facility characteristics (2.2%). Table 1 displays the specificcategories for the reported root causes.

3.3. Effectiveness of action plans

The outcomes measures were classified into three maincategories including structure (39.8%), process (54.1%) andoutcome (6.8%) indicators. Table 2 outlines the actions plansthat were reported to be most effective. They were organizedinto three main categories: (1) standardization, (2) proceduralchanges at the bedside and (3) staffing/scheduling assignments.Standardization included actions to improve verbal communi-cation of fall risk, use of an interdisciplinary team andproviding appropriate fall prevention interventions to patientsin a timely manner. Procedural changes at the bedside includeddeveloping and implementing tools to improve fall riskassessments or reassessments and an intervention targeting aspecific patient population. Table 3 summarizes the event typeand associated root causes and effective action plans.

The majority of actions resulted in change that wasdocumented as “better” or “much better” (68.4%).Approximately 17% of actions were not measured, reportedor implemented. No actions were reported as having aworse outcome.

4. Discussion

This is the first study to review reports of serious falls onpsychiatric units in a large healthcare system. Examples ofevents analyzed in the review include a patient who wasoversedated on antipsychotic medications and fell whilegetting up from awheelchair, a patientwho fell after attemptingto attack a nursing assistant and a patientwho became fearful ofhis surroundings and fell while kicking an elevator door.

Our first finding, that patients on psychiatric units fallwhen they are attempting to get up, while ambulating orwhen using the bathroom, is supported in the literature [4]. Itis important to note that psychiatric patients fall during thesame activities as other medical inpatients. Many of the casesincluded in the analysis revealed that staff on mental healthunits may not see psychiatric patients as medically ill orparticularly frail, and thus may overlook their need forassistance to avoid falling. This was evidenced by review ofthe descriptions and root causes that lead to the fall event.From our analysis, over 20% of falls occurred because

assessment for fall risk and the implementation of fallprevention interventions were insufficient. In addition, manyassistive devices such as walkers and canes can be used asweapons on a psychiatric unit and so may not be as readilyavailable to patients in these environments.

One type of fall that was unique to inpatient mental healthunits is falls which occurred while the patient was assaultingother patients or staff. These events were common, accountingfor 8.5% of fall events included in the analysis. It is possiblethat the increased rate of falls on mental health units [4] maybe the result of behavioral discontrol including assaults.

The most common root causes associated with falls onmental health units involved the physical environment ofcare. Examples included that the physical layout of the unitdid not allow for efficient mobility from patients' rooms tothe common activity area, missed repairs (such as loose ormissing floor tiles) and poor lighting. While all psychiatricunits in VA are systematically reviewed for hazards that canlead to self-harm [28], environmental review for fallinghazards may be equally important.

The lack or inappropriate use of equipment was also acommon root cause associated with falls (8.9%). Some of theRCA reports that were reviewed discussed determining thefeasibility of using fall prevention interventions such as bedor chair alarms which may not be appropriate for use on thepsychiatric unit because the sound of the alarm may causeincreased agitation for patients with dementia and loosecords represent a hazard for self-harm. RCA reports alsodiscussed the lack of nursing call light systems and not usinghip protectors, geriatric chairs or bedside mats as factorswhich may have increased the severity of injury. Many ofthese devices cannot be used on psychiatric units because ofthe risk for self-harm, harming others or because the patientis combative or uncooperative. It remains to be determined ifmodifications can be made to allow these interventions to befeasible on a mental health unit.

In many reports, the current system for falls assessment/reassessment was reported as needing improvement (8.9%). Insome cases, the current fall risk assessment tool was not ableto identify patients at high risk to fall, or the nursing fall riskassessment was being interpreted differently by staff. In othercases, even when a standardized and validated assessment toolwas used, such as the Morse Fall Risk Assessment, it wasincorrectly scored and interpreted by staff. In these cases, staffeducation about fall risk assessment is esential; however, it is

Table 2Most effective RCA action plans

Category Examples

StandardizationVerbal actions to improvecommunication of risk

• Nurse manager will establish written criteria and provide education on communicating observations ofchanges in patient conditions from nursing assistants to LPNs and RNs, and RNs to providers• Develop and implement a plan for formalized handoff communication between regular mental health staff,on-call residents and the charge nurse• Establish direct physician-to-physician communication prior to the transfer of surgical patients

Interdisciplinary team • The mental health service in collaboration with the medicine service will develop criteria for acceptingpatients with medical problems into mental health• A mental health interdisciplinary team will design an evidence-based plan to safely manage the mixedpatient population within the unit

Providing equipment • Patients on the acute psychiatric unit will be evaluated for the use of bed/chair alarms and bedside mats whenthey are identified as being at risk for falls• Install assistive devices in bathrooms of psychiatric unit• Hip protectors will be provided for high-fall-risk patients

Procedural changes at the bedsideTools to improve fall riskassessments/reassessments

• Initiate standing orders at admission that blood pressure be taken sitting and standing(for determination of hypostatic orthotension)• Treatment plan activity orders should include physical restrictions for the activity/day room• Add questions to the history and progress notes template that address risk factors for falls such as history offalls or assaultive behavior• Develop a template for documentation of fall prevention measures to be completed on all patients identified ata risk for falls• Patients at high risk for falls on inpatient psychiatry unit should have the Morse Fall Risk Assessmentembedded in every nursing note to reinforce information• Remove Morse Fall Risk Assessment from nursing admission assessment, and rebuild a separate assessmentthat includes interventions and quick orders

For a specific population • Develop and pilot comfort rounds for mobile, cognitively impaired patientsStaffing/schedulingassignments

• Reevaluate staffing methodology to include consideration of patient acuity

309A. Lee et al. / General Hospital Psychiatry 34 (2012) 304–311

critical to not stop at the education. Any measure ofimprovement must include a process measure to ensure thatstaff behaviors and compentencies have changed andvalidation to ensure high-risk patients are identified.

In 8.9% of identified root causes, RCA teams documentedthat a lack of verbal communication of fall riskmay have led tothe patient's fall. For example, although a patient's orthostatichypotension was identified by nursing and physical therapystaff, this informationwas not clearly communicated to higher-level practitioners. In another case, the lack of verbalcommunication may have also delayed or prevented assess-ment, evaluation and implementation of appropriate fallprevention interventions. Again, medical issues and risk forfallingmay have to take a backseat tomental status and suiciderisk assessment, but it is critical to remember to communicateall important information at handovers. This can be facilitatedby the use of a standardized checklist, so that importantinformation does not have be remembered by the staff.

The results also indicated that 6.7% of cases revealed a needfor improved medication management. Importantly, thesewere equally divided into the need formoremedication and theneed for less medication. Examples included the following:patients inadequately medicated for the control of agitation,patients taking multiple medications which caused orthostatichypotension, poor communication regarding medicationsbetween the nursing staff and psychiatrists, and the lack ofcompletion of a medication risk assessment by the provider

upon the patient's admission to the unit. Likely involvement ofthe whole treatment including a clinical pharmacist wouldresult in the best oportunity to optimally manage medications.Although the primary focus on a psychiatric unit is to alleviatepsychiatric symptoms, the optimization of medications toreduce falls risk remains a priority.

Actions that were identified as both improving care andthat were adequately measured included standardizingprocesses such as patient handovers and communication offall risk, consulting with other medical specialists to evaluateboth psychiatric and medical issues upon admission to theunit, and appropriate evaluation and use of fall-risk reductionequipment. In addition, patient safety managers identifiedprocedural changes at the bedside including standing orders,admission questions about fall risk and standardized fallassessments. Finally, taking fall risk into account whenscheduling and assigning staff was an effective action.

4.1. Limitations

This study has several limitations. First, the resultsobtained are based solely on the written reports of the patientsafety managers at local VHA facilities. We did notindependently verify the process by which root causeswere identified or action plans were developed. Second, it isdifficult to determine which actions were responsible forreductions in falls occurring in the psychiatric unit since

Table 3Event type and associated root causes and effective action plans

Event type Root causes Effective actions

Getting up • Lack of use of injury-minimizing/prevention interventions,such as a nursing call light system, hip protectorsand bedside mats

• The mental health service in collaboration with themedicine service will develop criteria for accepting patientswith medical problems into mental health

• Scarce supply of geriatric chairs limited the placementoptions of the patient

• Patients on the acute psychiatric unit will be evaluatedfor the use of bed/chair alarms and bedside mats when theyare identified as being at risk for falls• Patient's orthostasis was not communicated to

higher-level practitioners • Initiate standing orders at admission that blood pressurebe taken sitting and standing (for determination of orthostatic hypotension)• Patient was inadequately medicated for the control of agitation

• No means by which unit staff could discuss medicationneeds with other psychiatrists responsible for the patient• Lack of a process to assess fall risk and implementprevention interventions upon admission to the mentalhealth unit

Walking orrunning

• Physical layout of the unit increases ambulation distancefor the patient

• Nurse manager will establish written criteria and provideeducation on communicating observations of changes in patient conditionfrom nursing assistants to LPNs and RNs, and RNs to providers• Delay in repair of missing floor tile• Hip protectors will be provided to high-fall-risk patients• The patient's room was poorly lit; therefore, a tripping

hazard would not be seen • Fall-risk patients should have comprehensive activity orders,such as “only ambulate with assistance.”• Patients at high risk for falls on inpatient psychiatry unit shouldhave the Morse Fall Risk Assessment embedded in every nursingnote to reinforce information

• Use of a standard wheelchair by unsteady patientsas an ambulatory aid

• Remove Morse Fall Risk Assessment from nursingadmission assessment, and rebuild a separate assessment thatincludes interventions and quick orders

• Due to time constraints, staff incompletely reviewed patient'stransfer records and did not identify the patient was at a falls risk• Fall risk assessment and precautionary measures were notaddressed after a change in the patient's condition

Bathroomrelated

• Lack of use of bathroom assistive devices • Develop and pilot comfort rounds for mobile,cognitively impaired patients• Lack of use of a nursing call light system by the patient• Install assistive devices in bathrooms of psychiatric unit• Lack of individualized care planning for patients at high risk to fall

Behaviorrelated

• Mixing dementia psychiatric patients with acutely psychoticpatients on a locked unit increased the probability of patient injury

• Develop and implement a plan for formalized handoffcommunication between regular mental health staff, on-call residentsand the charge nurse• Veteran's assaultive behavior was not communicated between

staff at the change of shift • Reevaluate staff methodology to include consideration ofpatient acuity• Due to the patient's diagnosis of schizophrenia and an extensive

history of violent behavior, there was a likelihood that the patientwould become unpredictably uncontrollable and at high riskfor self-endangerment and endangering staff

• A mental health interdisciplinary team will design anevidence-based plan to safely manage the mixed patientpopulation within the unit

• No training for prevention and management of aggressivebehavior in patients was provided to staff members

• Add questions to the history and progress notes template thataddress risk factors for falls such as history of falls orassaultive behavior• Inadequate staff to monitor the level and intensity

of patients on the unit

310 A. Lee et al. / General Hospital Psychiatry 34 (2012) 304–311

many of the facilities implemented several actions simulta-neously. Third, the patients included in this analysis are fromVHA hospitals and so may not accurately reflect the generalpopulation. Root cause analysis reports are deidentified, andtherefore, we could not obtain detailed information about thecharacteristics of the population studied.

5. Conclusion

These results describe the location and activity surround-ing falls that occur in psychiatric units resulting in moderateto serious injury. Our findings provide insight into the rootcause of the events and offer some suggestions on how toimplement a successful action plan. Based on these results,we make the following recommendations for fall reductionon psychiatric units:

• Assess the environment. Ensure that the psychiatricunit provides a safe environment for patients byplacing high-fall-risk patients closer to the nursingstation for observation, regularly checking for fallhazards such as loose floor tiles and having adequatelighting. These processes may be standardized throughthe use of a checklist. Signage on the unit thatidentifies patients at high risk to fall (e.g., having afalling star at the head of the patient's bed) can serve asa reminder to clinical staff and help facilitate handovercommunication that increased supervision for thepatient may be necessary. It may also be beneficialto implement structured, staff-led activities to keeppatients occupied.

• Provide equipment. Some options for fall preventionequipment that is appropriate for use on the psychiatricunit include the use of nonskid gripper socks, use of

311A. Lee et al. / General Hospital Psychiatry 34 (2012) 304–311

hip protectors, placing the patient's bed in the lowposition, placing mats near the bedside to minimizeinjuries if the patient rolls out of bed and the use ofbaby monitors for increased observation of the patientif a sitter is not available. The use of activity apronsmay also be helpful, particularly to keep patients withdementia occupied and from becoming increasinglyagitated throughout the day. In addition, new de-velopments will improve bed and chair alarms [6].Wireless bed and chair alarms have been developed,and in some models, the typical alarm sound can bereplaced with a more comforting human voice.

• Manage medications. Interdisciplinary teams (e.g.,physicians, nurses and pharmacists) should worktogether to optimally manage medications. Whilemany studies have demonstrated the relationshipbetween medications and increased fall risk, ouranalysis revealed an equal number of falls attributedto undermedication.

• Assess fall risk. Patients should be assessed for fallsrisk, at a minimum, when admitted to the hospital andwhen there has been a change in condition. Addition-ally, a standardized risk assessment tool should beutilized accompanied by staff education. Directlyobserving nursing staff as they utilize the tool onpatients may also be helpful in determining if high-riskpatients are being correctly identified.

Acknowledgments

This material is the result of work supported withresources and the use of facilities at the Veterans AffairsNational Center for Patient Safety Field Office in WhiteRiver Junction, Vermont. The views expressed in thisarticle do not necessarily represent the views of theDepartment of Veterans Affairs or of the United Statesgovernment. This study was not grant funded; there are noconflicts of interest.

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