Fall prevention in a hospital
- Use the organization plan of action / risk reduction strategies in the template (p.12) to prepare an Action Plan to manage risk of an adverse event in the scenario.
- Consider how this situation could be avoided.
- As a result of assessing the situation and researching best practices, develop a comprehensive recommendation for the key decision makers of this healthcare organization addressing the business problems, opportunities, and a possible course of action.
FRAMEWORK FOR ROOT CAUSE ANALYSIS AND CORRECTIVE ACTIONS*
The Joint Commission’s Framework for Root Cause Analysis and Action Plan provides an example of a comprehensive systematic
analysis. The framework and its 24 analysis questions are intended to provide a template for analyzing an event and an aid in organizing
the steps and information in a root cause analysis.
An organization can use this template to conduct a root cause analysis or even as a worksheet in preparation of submitting an analysis
through the online form on its Joint Commission Connect™ extranet site. Fully consider all possibilities and questions in seeking “root
cause(s)” and opportunities for corrective actions. Be sure to enter a response in the “Analysis Findings” column for each item.
Unexpected findings may emerge during the course of the analysis, or there may be some questions that do not apply in every situation.
For each finding continue to ask “Why?” and drill down further to uncover why parts of the process occurred or didn’t occur when
they should have. Significant findings that are not identified as root causes themselves have “roots.” “Corrective Actions” should be
developed for every identified root cause.
While the online form provides drop-down menus for many of the form’s cells, the options for these columns are provided here in the
following tables:
The following are in the Root Cause Analysis section:
Root Cause Types: Table A-1 (column 1)
Causal Factors/Root Cause Details: Table A-1 (column 2)
In the Corrective Actions section, the following are added:
Action Strength: Table A-2
Measure of Success: Table A-3
Sample Size: Table A-4
*Disclaimer: The framework found on Joint Commission Connect™ will show the most current iteration of this form.
Page 1 of 18
EVENT DESCRIPTION
When did the event occur?
Date:
Day of the week:
Detailed Event Description Including Timeline:
Diagnosis:
Medications:
Autopsy Results:
Past Medical/Psychiatric History:
Page 2 of 18
Time:
ROOT CAUSE ANALYSIS – QUESTIONS
#
Analysis
Questions
Prompts
1
What was the
intended process
flow?
List the relevant process steps as defined
by the policy, procedure, protocol, or
guidelines in effect at the time of the
event. You may need to include multiple
processes.
Examples of defined process steps may
include, but are not limited to:
• Site verification protocol
• Instrument, sponge, sharps count
procedures
• Patient identification protocol
• Assessment (pain, suicide risk,
physical, and psychological)
procedures
• Fall risk/fall prevention guidelines
Note : The process steps as they occurred in
the event will be entered in the next
question.
2
Were there any
steps in the
process that did
not occur as
intended?
Explain in detail any deviation from the
intended processes listed in Analysis
Question #1 above.
3
What human
factors were
relevant to the
outcome?
Discuss staff-related human performance
factors that contributed to the event.
Examples may include, but are not limited
to:
• Boredom
• Failure to follow established
policies/procedures
Analysis
Findings
Page 3 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
Prompts
Analysis
Findings
• Fatigue
• Inability to focus on task
• Inattentional blindness/confirmation
bias
• Personal problems
• Lack of complex critical thinking skills
• Rushing to complete task
• Substance abuse
• Trust
4
How did the
equipment
performance
affect the
outcome?
Consider all medical equipment and
devices used in the course of patient care,
including automated external defibrillator
(AED) devices, crash carts, suction,
oxygen, instruments, monitors, infusion
equipment, etc. In your discussion,
provide information on the following, as
applicable:
• Descriptions of biomedical checks
• Availability and condition of
equipment
• Descriptions of equipment with
multiple or removable pieces
• Location of equipment and its
accessibility to staff and patients
• Staff knowledge of or education on
equipment, including applicable
competencies
• Correct calibration, setting, operation
of alarms, displays, and controls
5
What controllable
environmental
What environmental factors within the
organization’s control affected the
Page 4 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
Prompts
factors affected
the outcome?
outcome? Examples may include, but are
not limited to:
• Overhead paging that cannot be
heard in physician offices
• Safety or security risks
• Risks involving activities of visitors
• Lighting or space issues
The response to this question may be
addressed more globally in Question #17.
This response should be specific to this
event.
6
What
uncontrollable
external factors
influenced the
outcome?
Identify any factors the health care
organization cannot change that
contributed to a breakdown in the
internal process, for example natural
disasters.
7
Were there any
other factors that
directly influenced
this outcome?
List any other factors not yet discussed.
8
What are the
other areas in the
health care
organization
where this could
happen?
List all other areas in which the potential
exists for similar circumstances. For
example:
• Inpatient surgery/outpatient surgery
• Inpatient psychiatric care/outpatient
psychiatric care
• Identification of other areas within
the organization that have the
potential to impact patient safety in a
similar manner. This information will
help drive the scope of your action
Analysis
Findings
Page 5 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
Prompts
Analysis
Findings
plan.
9
Was staff properly
qualified and
currently
competent for
their
responsibilities?
Include information on the following for
all staff and providers involved in the
event. Comment on the processes in
place to ensure staff is competent and
qualified. Examples may include but are
not limited to:
• Orientation/training
• Competency assessment (What
competencies do the staff have and
how do you evaluate them?)
• Provider and/or staff scope of
practice concerns
• Whether the provider was
credentialed and privileged for the
care and services he or she rendered
• The credentialing and privileging
policy and procedures
• Provider and/or staff performance
issues
10
How did actual
staffing compare
with ideal level?
Include ideal staffing ratios and actual
staffing ratios along with unit census at
the time of the event. Note any unusual
circumstance that occurred at this time.
What process is used to determine the
care area’s staffing ratio, experience level,
and skill mix?
11
What is the plan
for dealing with
staffing
contingencies?
Include information on what the health
care organization does during a staffing
crisis, such as call-ins, bad weather, or
increased patient acuity. Describe the
Page 6 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
Prompts
Analysis
Findings
health care organization’s use of
alternative staffing. Examples may
include, but are not limited to:
• Agency nurses
• Cross training
• Float pool
• Mandatory overtime
• PRN pool
12
Were such
contingencies a
factor in this
event?
If alternative staff were used, describe
their orientation to the area, verification
of competency, and environmental
familiarity.
13
Did staff
performance
during the event
meet
expectations?
Describe whether staff performed as
expected within or outside of the
processes. To what extent was leadership
aware of any performance deviations at
the time? What proactive surveillance
processes are in place for leadership to
identify deviations from expected
processes? Include omissions in critical
thinking and/or performance variance(s)
from defined policy, procedure, protocol,
and guidelines in effect at the time.
14
To what degree
was all the
necessary
information
available when
needed?
Accurate?
Complete?
Discuss whether patient assessments were
completed, shared, and accessed by
members of the treatment team, to
include providers, according to the
organizational processes. Identify the
information systems used during patient
care. Discuss to what extent the available
patient information (e.g., radiology
Page 7 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
Prompts
Unambiguous?
studies, lab results, or medical record) was
clear and sufficient to provide an
adequate summary of the patient’s
condition, treatment, and response to
treatment. Describe staff utilization and
adequacy of policy, procedure, protocol,
and guidelines specific to the patient care
provided.
15
To what degree is
communication
among
participants
adequate?
Analysis of factors related to
communication should include evaluation
of verbal, written, electronic
communication or the lack thereof.
Consider the following in your response,
as appropriate:
• The timing of communication of key
information
• Misunderstandings related to
language/cultural barriers,
abbreviations, terminology, etc.
• Proper completion of internal and
external hand-off communication
• Involvement of patient, family, and/or
significant other
16
Was this the
appropriate
physical
environment for
the processes
being carried out?
Consider processes that proactively
manage the patient care environment.
This response may correlate to the
response in Question #6 on a more
global scale. What evaluation tool or
method is in place to evaluate process
needs and mitigate physical and patient
care environmental risks? How are these
process needs addressed
organizationwide? Examples may include,
Analysis
Findings
Page 8 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
Prompts
Analysis
Findings
but are not limited to:
• Alarm audibility testing
• Evaluation of egress points
• Patient acuity level and setting of
care managed across the continuum
• Preparation of medication outside of
pharmacy
17
What systems are
in place to identify
environmental
risks?
Identify environmental risk assessments.
Does the current environment meet
codes, specifications, regulations? Does
staff know how to report environmental
risks? Was there an environmental risk
involved in the event that was not
previously identified?
18
What emergency
and failure-mode
responses have
been planned and
tested?
Describe variances in expected process
due to an actual emergency or failure
mode response in connection to the
event. Related to this event, what safety
evaluations and drills have been
conducted and at what frequency (e.g.
mock code blue, rapid response,
behavioral emergencies, patient abduction
or patient elopement)? Emergency
responses may include, but are not limited
to:
• Fire
• External disaster
• Mass casualty
• Medical emergency
Failure mode responses may include, but
are not limited to:
• Computer down time
• Diversion planning
Page 9 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
19
How does the
organization’s
culture support
risk reduction?
20
What are the
barriers to
communication of
potential risk
factors?
21
How does
leadership address
the continuum of
patient safety
events, including
Prompts
Analysis
Findings
• Facility construction
• Power loss
• Utility issues
How does the overall culture encourage
change, suggestions, and warnings from
staff regarding risky situations or
problematic areas?
• How does leadership demonstrate
the organization’s culture and safety
values?
• How does the organization measure
culture and safety?
• How does leadership address
disruptive behavior?
• How does leadership establish
methods to identify areas of risk or
access employee suggestions for
change?
• How are changes implemented?
Describe specific barriers to effective
communication among caregivers that
have been identified by the organization.
For example, residual intimidation or
reluctance to report co-worker activity.
Identify the measures being taken to
break down barriers (e.g. use of SBAR). If
there are no barriers to communication
discuss how this is known.
Does leadership demonstrate
accountability for implementing measures
to reduce risk for patient harm? Has
leadership provided for required
resources or training? Does leadership
Page 10 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
#
Analysis
Questions
Prompts
close calls,
adverse events,
and unsafe,
hazardous
conditions?
How can
orientation and
in-service training
be improved?
communicate corrective actions stemming
from any analysis following reported
risks?
23
Was available
technology used
as intended?
Describe variances in the expected
process due to education, training,
competency, impact of human
factors, functionality of equipment,
and so on:
• Was the technology designed to
minimize use errors or easy-to-catch
mistakes?
• Did the technology work well with
the workflow and environment?
• Was the technology used outside of
its specifications?
24
How might
technology be
introduced or
redesigned to
reduce risks in the
future?
Describe any future plans for
implementation or redesign. Describe the
ideal technology system that can help
mitigate potential adverse events in the
future.
22
Analysis
Findings
Describe how orientation and ongoing
education needs of the staff are evaluated
and discuss its relevance to event. (e.g.,
competencies, critical thinking skills, use
of simulation labs, evidence based
practice, etc.)
Page 11 of 18
Root Cause Types
(Table A-1)
Causal
Factors/Root
Cause Details
(Table A-1)
CORRECTIVE ACTIONS
Root Cause
Types
(Table A-1)
Causal
Factors/Roo
t Cause
Details
(Table A-1)
Action
Strength
(Table A-2)
Corrective Actions
Action Item #1:
Action Item #2:
Action Item #3:
Action Item #4:
Action Item #5:
Action Item #6:
Action Item #7:
Action Item #8:
Page 12 of 18
Measure of Success
(Numerator /
Denominator) (Table A3)
Sample
Size
(Table A-4)
BIBLIOGRAPHY
Cite all books and journal articles that were considered in developing this root cause analysis and action plan.
Page 13 of 18
TABLE A-1. ROOT CAUSES
Root Cause Types
Communication
factors
Causal Factors / Root Cause Details
• Communication breakdowns between and among teams, staff, and providers
• Communication during handoff, transition of care
• Language or literacy
• Availability of information
• Misinterpretation of information
• Presentation of information
Environmental
factors
•
•
•
Noise, lighting, flooring condition, etc.
Space availability, design, locations, storage
Maintenance, housekeeping
Equipment/device/
supply/
healthcare IT factors
•
•
•
•
•
•
Equipment, device, or product supplies problems or availability
Health information technology issues such as display/interface issues (including display of information),
system interoperability
Availability of information
Malfunction, incorrect selection, misconnection
Labeling instructions, missing
Alarms silenced, disabled, overridden
Task/process
factors
•
•
•
Lack of process redundancies, interruptions, or lack of decision support
Lack of error recovery
Workflow inefficient or complex
Staff performance
factors
•
•
•
Fatigue, inattention, distraction or workload
Staff knowledge deficit or competency
Criminal or intentionally unsafe act
Team factors
•
•
•
Speaking up, disruptive behavior, lack of shared mental model
Lack of empowerment
Failure to engage patient
Page 14 of 18
Management/
supervisory/
workforce factors
•
•
•
•
•
Disruptive or intimidating behaviors
Staff training
Appropriate rules/policies/procedure or lack thereof
Failure to provide appropriate staffing or correct a known problem
Failure to provide necessary information
Organizational
culture/leadership
•
Organizational-level failure to correct a known problem and/or provide resource support including
staffing
Workplace climate/institutional culture
Leadership commitment to patient safety
•
•
Adapted from: Department of Defense, Patient Safety Program. PSR Contributing Factors List – Cognitive Aid, Version 2.0. May
2013.
Page 15 of 18
TABLE A-2. ACTION STRENGTH
Action Strength
Stronger
Actions
(These tasks
require less
reliance
on humans
to remember to
perform the task
correctly)
Intermediate
Actions
Action Category
Architectural/physical plant
changes
New devices with usability
testing
Engineering control (forcing
function)
Simplify process
Standardize on equipment
or process
Tangible involvement by
leadership
Redundancy
Increase in staffing/decrease
in workload
Software enhancements,
modifications
Eliminate/reduce
distractions
Education using simulationbased training, with periodic
refresher sessions and
observations
Checklist/cognitive aids
Eliminate look- and soundalikes
Standardized communication
Example
Replace revolving doors at the main patient entrance into the building with powered
sliding or swinging doors to reduce patient falls.
Perform heuristic tests of outpatient blood glucose meters and test strips and select
the most appropriate for the patient population being served.
Eliminate the use of universal adaptors and peripheral devices for medical
equipment and use tubing/fittings that can only be connected the correct way (e.g.,
IV tubing and connectors that cannot physically be connected to sequential
compression devices [SCDs]).
Remove unnecessary steps in a process.
Standardize the make and model of medication pumps used throughout the
institution. Use bar coding for medication administration.
Participate in unit patient safety evaluations and interact with staff; support the
RCA2 process (root cause analysis and action); purchase needed equipment; ensure
staffing and workload are balanced.
Use two registered nurses to independently calculate high-risk medication dosages.
Make float staff available to assist when workloads peak during the day.
Use computer alerts for drug–drug interactions.
Provide quiet rooms for programming patient-controlled analgesia (PCA) pumps;
remove distractions for nurses when programming medication pumps.
Conduct patient handoffs in a simulation lab/environment, with after-action
critiques and debriefing.
Use pre-induction and pre-incision checklists in operating rooms. Use a checklist
when reprocessing flexible fiber optic endoscopes.
Do not store look-alikes next to one another in the unit medication room.
Use read-back for all critical lab values. Use read-back or repeat-back for all verbal
Page 16 of 18
Weaker Actions
(These tasks rely
more on
humans to
remember
to perform the
task correctly)
tools
Enhanced documentation,
communication
medication orders. Use a standardized patient handoff format.
Highlight medication name and dose on IV bags.
Double checks
Warnings
New procedure/
memorandum/policy
Training
One person calculates dosage, another person reviews their calculation.
Add audible alarms or caution labels.
Remember to check IV sites every 2 hours.
Demonstrate correct usage of hard-to-use medical equipment.
Reference: Action Hierarchy levels and categories are based on Root Cause Analysis Tools, VA National Center for Patient Safety,
http://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf. Examples are provided here.
Source: National Patient Safety Foundation. RCA2 Improving Root Cause Analyses and Actions to Prevent Harm. Boston, MA: National Patient
Safety Foundation; 2015. Reproduced with permission.
Page 17 of 18
TABLE A-3. MEASURE OF SUCCESS
Fraction Part
Numerator
Defined
The number of
events being
measured
Identified
Ask a specific
question—what are
you measuring?
Example
Falls that resulted in hip fractures
in diabetic patients over 70 years of
age
Denominator
All the opportunities
in which the event
could have occurred
Identify the patient
population from
which to collect the
information.
The number of diabetic patients on
a unit who are older than 70 years
of age
TABLE A-4. SAMPLE SIZE*
Population Size
Sample
Fewer than 30 cases
100% of cases
30 to 100 cases
30 cases
101 to 500 cases
50 cases
Greater than 500 cases
70 cases
*The sampling methodology was determined using quality assurance sampling methods which determines the sample size needed to be able
to say from a sample of cases that the “defect” rate is less than a specified amount (here we used 10%) with 95% confidence if no
“defects” are found in the sample.
Page 18 of 18