RCA PRIYA FALL FOR PROBLEM ROOT CAUSE AND

RCA PRIYA FALL FOR PROBLEM ROO

1. RCA : Unwitnessed inpatient Fall
PriyawathyD/O Ravi Chandaran
STAFF NURSE 1
WG2 MEDICAL WARD
2023

2. Incident Description
Female patient admittedon 31/01/2023 @1155hrs with diagnosis of
compression of L4 Fracture underDr B. Patient history of dementia and had
history of fall 2 weeks ago and complaint of lower back pain and right leg
pain.
Received patient from ED and admitted in ward WG 2 bed 232A.
General condition of patient alert and conscious
Onadmission, Flow flex done negative, anemia profile, MSO1 and ABG done.
VitalsignsonadmissionBP:130/86 mmHg, Temp: 36.3,Pulse: 73 Bpm, Spo2>
98 % on room air and RR 20.

3. P
ROOT CAUSE ANALYSIS
TRIGGER RCAB
1. Trigger RCA
Process
1.Inconsistent or incomplete communication of patient risk for falls between
ward aid.
2.Patient did not seek help while toileting.
3.patient forgot or chose not to use call bell.
4.Patient unaware of the own risk of fall
2.Mandate,
Organise the
RCA Team
RCA meeting was mandated by Nursing team:
•Staffs involved
•Nurse manager
•Nurse Educator
•ADON /DDON
1.3 Plan the RCAFocus group initiated and case discussed.
PLAN

4. A
ROOT CAUSE ANALYSIS
GRASPSITUATION
Define Event
(brief problem
statement)
Patient was found inside the toilet in sitting position. And after further
investigation found that patient had fall inside the toilet.
Gather Initial
Information
•Situation happened in WG2 BED 232A.
•Lower cot-side by ward aid F as patient request to rest the leg and drink
water.
•Ward aid F asked patient whether want to urinate or not but the patient
refuse to go toilet to urinate.
•Ward aid F wanted to rails up the cot-side but patient refuse strongly.
•Ward aid F attached the call bell and informed patient to call for assistance
if required and left the place.
•Short awhile ,Patient claim that she had urgency to pass urine and when to
toilet without press the call bell.
•Patient become unbalance and fell down inside the toilet.
ANALYSED : WHAT happened?

5. ROOT CAUSE ANALYSIS
GRASP SITUATION
Understand
the Problem
CHRONOLOGY OF EVENTS
2/1/2023
DATE/TIME EVENT
INFORMATION
SOURCE
1845 hr Patient daughter came to nursing counter query about the mother
(patient) not in the bed room 232A. Notice patient not around, than when
to toilet to check and found toilet unlock. When check inside toilet found
patient in sitting position in toilet floor. Patient alert and conscious. After
that assist patient from toilet to the bed helped by patient grandson too.
Assessment was done and notice had laceration wound over left upper
eyebrow, bruises, swelling and found bleeding. Immediately place some
pressure on top of open wound at left upper eye brow with gauze and
micropore. Parameter taken Temp: 37.1, HR: 90/min, BP: 167/85mmHg,
SPO2: >95% under Room air. Both side rails up accompany by family at
bedside.
1900 hrCall up ED Dr. S and informed about fall incident. Dr noted. Second
assessment done by Dr.Sto the patient. The open wound at the left upper
left eye brow cleaned with normal saline and apply sterile strips x5 +
opsitedressing. Dressing was done by Dr.S. Dr.Salso advice for MRI brain.
MRI was done-Nil fracture seen.
1905 hrSN A called and inform to the primary Dr.Babout the incident. Dr.BNoted
and came to review the patient.
ANALYSED : WHAT happened?
A

6. ROOT CAUSE
ANALYSIS
GRASP SITUATION
Understand
the Problem
CHRONOLOGY OF EVENTS
DATE/TIME EVENT
INFORMATIO
N SOURCE
2000 hr Case investigated from ward aid F :
Lower cot-side by ward aid as patient request to rest the leg and
drink water. Ward aid F asked patient whether want to urinate or
not but the patient refuse to go toilet to urinate. Ward aid F
wanted to rails up the cot-side but patient refuse strongly. Ward
aid attached the call bell and informed patient to call for
assistance if required and left the place.
Patient claim that she had urgency to pass urine and when to
toilet without press the call bell. Patient become unbalance and
fell down inside the toilet.
ANALYSED : WHAT happened? A

7. ROOT CAUSE ANALYSIS
FIND CAUSES
Identify
Proximate
Cause
Interview staffs inthe focus group by Nursing Manager:
Nurses/Ward aid:
-Ward aid lack of knowledge of patient risk for fall.
-Inconsistent communication between ward aid and nurse.
-Poor nursing judgement of the patient
Patient:
1. Wanted to try to stand up to pass urine as feel not satisfied
2.Disease process–admitted due to fracture of L4 and history of dementia
and fall at home
3.Lack of awareness about self ability.
4. Did not call for assistance
5. Forgetful
ANALYSED : WHY it happened? A

8. 8
Inpatient
falls
Man
(Patient )
METHOD
Material
Man
(Nurse)
N/A
1.Ward aid lack of knowledge
of patient risk for fall.
2.Inconsistent communication
between ward aid and nurse.
3.Poor nursing judgement of
the patient
1.No proper communication between
patient and ward aid/nurse
2. Staff failed to go back to check again
the patient.
1.Gait imbalance.
2.Disease process.
3.Lack of awareness about self ability.

9. ACTION Plan
NoRoot Cause Preventive Action Implementations Action
1. In consistent or incomplete communication of patient
risk for falls between nurse and ward aid.
Ensure staff is adequately
trained on the fall risk
assessment tool.
Educate staff/ training on
patient’s Morse Fall Scale.
2. Patient awareness and acknowledgment of their own
risk for falls.
1.Educate patient and
signingof patient
agreement during
admission by using patient
family rights’ s form.
Educateand reinforce every
shift.
3. Patient did not seek help while toileting. Implement hourly round with
proactive toileting.
Frequent changediapers,
assist toilet or offer urinal.
4. patient forgot or chose not to use call bell. Educate patient on the use of
callbell.
Advised family member to
lodger
Reinforce to use call bell
every time attend patient.